Concepts, disciplines and politics: on ‘structural violence’ and the ‘social determinants of health’

Naming and Framing: Six Principles for Embedding Health Equity Language in Policy Research, Writing, and Practice

Policy Points Science communication and health policy language often fail to adequately define and contextualize systemic barriers-like structural racism and wealth inequity-that contribute to disparities in health outcomes. Health policy practitioners should understand best practices for communicating research and policy findings to various audiences and understand how to disseminate messages that are culturally and linguistically responsive to different community needs. As no perfect term exists, adopting health equity language principles can help health policy practitioners avoid dehumanizing and exclusionary language as well as ill-suited terminology that perpetuates racist systems and leads to inequities in population health.

CONTEXT

Language specificity in research, advocacy, and writing is an important tool to ensure more equitable health policies. All health policy practitioners working at the intersection of health care, health policy, and health equity have a role in upholding ethical standards that promote the use of humanizing, inclusive, and antisupremacist language.

METHODS

We conducted an environmental scan and synthesized themes across commonly used and publicly available health equity language guides to provide specific guidance to health policy practitioners to inform their policy research, analysis, writing, and dissemination.

FINDINGS

We identify and describe six guiding principles to dismantle systems that work against the goals of health equity through policy-focused research, writing, and communications. These principles include avoiding blaming language, contextualizing health inequities, acknowledging that systems are not passive, understanding that one-size-fits-all terminology does not exist, seeking input from community members, and paying attention to omissions.

CONCLUSIONS

Applying these principles will better equip health policy practitioners to develop or inform equitable policies and meaningfully engage in dialogue with community members to advance equitable health policy.

Global Health and Peace: The Elusive Path with a Focus on Palestine, Ukraine, and Venezuela

The interrelationality of health and peace is complex, multifactorial, and imbued with political and economic challenges. Peace and health outcomes reflect shared fundamental values related to the achievement of a balanced holistic condition on the individual and collective level. This causal relationship between social inequity and health requires special attention be paid to the impact of political instability and structural violence on undermining health systems in conflict zones. The mutual dependency between peace and health means that peace cannot be achieved without the existence of physical, mental, social, and spiritual health, and holistic health cannot be sustained under violent conditions. The interrelationality of peace and health as mutual conditions shapes our understanding of global solidarity and advocacy in relation to health diplomacy and peace promotion if addressed equally across all conflict zones. This commentary analyzes the unique interdisciplinary contextual factors that contribute to, or undermine the realization of global health and peace in three active conflict zones: Palestine, Ukraine, and Venezuela. Contextual analysis, review of the evidence, and synthesis of the authors' perspectives were used. The health-peace nexus remains a theoretical approach and lacks real application in most settings under crisis. Peace is a multifaceted phenomenon that necessitates the participation, dedication, and action of all sectors and stakeholders in global societies, including health policymakers, scientists, professionals, and people. Both the "right to health" and the "right to peace" even at the minimum remains unfulfilled, particularly in Palestine, and can be realized through two trajectories: (1) honest, responsible, and fair accountability, transparency, and political commitment empowered by reliable global health diplomacy for maintaining peace, eliminating the roots of injustice, and protecting health systems, and (2) equitable and real implementation of peace-health approaches, policies and actions driven by monitoring mechanisms that promote health, well-being, health security and equity for all nations under conflicts.

Recontextualization and Imagination: The Public Health Professional and the U.S. Health Care System

Based on a qualitative study, this paper explores how United States public health professionals view and think about the existing U.S. healthcare system, while also allowing these study participants to imagine new ways of structuring and practicing public health. Using semi-structured qualitative interviews, I show how public health professionals engage with the concept of "the social" and their personal experiences with public health to question the status quo. By giving public health professionals space in which to imagine changes and different ways of practicing public health, I demonstrate the effectiveness of imagination as a capacity that public health professionals possess to take the lead in creating the changes they hope for.

Social, cultural and political conditions for advancing health equity: examples from eight country case studies (2011-2021)

Progress in addressing systematic health inequities, both between and within countries, has been slow. However, there are examples of actions taken on social determinants of health and policy changes aimed at shaping the underlying sociopolitical context that drives these inequities.Using case study methodology, this article identifies five countries (Ethiopia, Jordan, Spain, Sri Lanka and Vietnam) that made progress on health equity during 2011-2021 and three countries (Afghanistan, Nigeria and the USA) that had not made the same gains. The case studies revealed social, cultural and political conditions that appeared to be prerequisites for enhancing health equity.Data related to population health outcomes, human development, poverty, universal healthcare, gender equity, sociocultural narratives, political stability and leadership, governance, peace, democracy, willingness to collaborate, social protection and the Sustainable Development Goals were interrogated revealing four key factors that help advance health equity. These were (1) action directed at structural determinants of health inequities, for example, sociopolitical conditions that determine the distribution of resources and opportunities based on gender, race, ethnicity and geographical location; (2) leadership and good governance, for example, the degree of freedom, and the absence of violence and terrorism; (3) a health equity lens for policy development, for example, facilitating the uptake of a health equity agenda through cross-sector policies and (4) taking action to level the social gradient in health through a combination of universal and targeted approaches.Reducing health inequities is a complex and challenging task. The countries in this study do not reveal guaranteed recipes for progressing health equity; however, the efforts should be recognised, as well as lessons learnt from countries struggling to make progress.

Re-politicizing the WHO's social determinants of health framework

Although the World Health Organization's (WHO's) framework on social and structural determinants of health and health inequities (SSDHHI) has done much to raise awareness of these determinants, it does not go far enough in considerations of politics and power. The framework has become more de-politicized since its publication, with the definition of social determinants shifting toward downstream and individualized factors. In the meantime, new research fields on legal, commercial and political determinants of health and health inequities have emerged; however, these have not become integrated adequately into broader SSDHHI frameworks. To address these challenges, we argue for a re-politicization and an expansion of the WHO's framework by including the agents who have power over shaping structural determinants and the ways they use power to shape these determinants. We also provide a more detailed conceptualization of structural determinants to facilitate research. We propose a guideline for evaluating studies according to the extent to which they point upstream versus downstream and incorporate agents and considerations of power. We then use this framework to encourage more research on associations among agents, mechanisms of power, and structural determinants; how changes in structural determinants affect power dynamics among agents; and a wider focus on structural determinants beyond laws and policies, such as broad economic and sociopolitical systems. We also urge researchers to consider societal and institutional forces shaping their research with respect to SSDHHI. Research based on this framework can be used to provide evidence for advocacy for structural changes and to build more just systems that respect the fundamental human right to a healthy life.

Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the "Pain-Movement Interface" to Guide Research and Clinical Care for Musculoskeletal Pain Conditions

Over 120 million Americans report experiencing pain in the past 3 months. Among these individuals, 50 million report chronic pain and 17 million report pain that limits daily life or work activities on most days (ie, high-impact chronic pain). Musculoskeletal pain conditions in particular are a major contributor to global disability, health care costs, and poor quality of life. Movement-evoked pain (MEP) is an important and distinct component of the musculoskeletal pain experience and represents an emerging area of study in pain and rehabilitation fields. This focus article proposes the "Pain-Movement Interface" as a theoretical framework of MEP that highlights the interface between MEP, pain interference, and activity engagement. The goal of the framework is to expand knowledge about MEP by guiding scientific inquiry into MEP-specific pathways to disability, high-risk clinical phenotypes, and underlying individual influences that may serve as treatment targets. This framework reinforces the dynamic nature of MEP within the context of activity engagement, participation in life and social roles, and the broader pain experience. Recommendations for MEP evaluation, encompassing the spectrum from high standardization to high patient specificity, and MEP-targeted treatments are provided. Overall, the proposed framework and recommendations reflect the current state of science in this emerging area of study and are intended to support future efforts to optimize musculoskeletal pain management and enhance patient outcomes. PERSPECTIVE: Movement-evoked pain (MEP) is a distinct component of the musculoskeletal pain experience and emerging research area. This article introduces the "Pain-Movement Interface" as a theoretical framework of MEP, highlighting the interface between MEP, pain interference, and activity engagement. Evaluating and treating MEP could improve rehabilitation approaches and enhance patient outcomes.

The politicizing clinic: insights on 'the social' for mental health policy and practice

PURPOSE

In this paper, we explore how Brazilian socially sensitive therapy can respond to care-users' desire to change the social and political forces shaping their lives. We use this case to demonstrate the limits of the "social determinants of health" agenda which, when operationalized, tends to leave questions of lasting structural change aside.

METHODS

We report on mixed methods ethnographic and epidemiological results from the 1982 Pelotas (Brazil) birth cohort study, a prospective study of 5914 children. Ethnographic analysis explored the cyclical relationship between schooling, mental health care, conceptualizations of mental distress, social and political engagement, and experiences with diverse forms of discrimination. Epidemiological bivariate and multivariate analyses examined differences in socio-political participation and the reporting of discrimination at different time-points for participants who used therapy with those who did not. Effect modification analysis tested the hypothesis that the socially empowering effects of therapy were greater for marginalized and minoritized youth.

RESULTS

Most young people living in situations of precarity experienced therapy, particularly when based in schools, to be a blame-inducing process. A more fulfilling and impactful therapeutic experience took shape when young people were able to shift the focus away from symptom reduction and behavioral management toward narrative life analyses, social debate, and political agency. Use of socially sensitive therapy was statistically associated with increased political participation and reporting of discrimination after controlling for confounders. The empowering effects of therapy were greater for those with less formal education and family income, but not for young people who identified as black, brown, or non-white.

CONCLUSION

The findings underscore the importance of considering agency, sociality, and politics when theorizing "the social" in clinical practice, and health and social policy.

What Are Healthy Societies? A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

While support for the idea of fostering healthy societies is longstanding, there is a gap in the literature on what they are, how to beget them, and how experience might inform future efforts. This paper explores developments since Alma Ata (1978) to understand how a range of related concepts and fields inform approaches to healthy societies and to develop a model to help conceptualize future research and policy initiatives.

METHODS

Drawing on 68 purposively selected documents, including political declarations, commission and agency reports, peer-reviewed papers and guidance notes, we undertook qualitative thematic analysis. Three independent researchers compiled and categorised themes describing the domains of a potential healthy societies approach.

RESULTS

The literature provides numerous frameworks. Some of these frameworks promote alternative endpoints to development, eschewing short-term economic growth in favour of health, equity, well-being and sustainability. They also identify values, such as gender equality, collaboration, human rights and empowerment that provide the pathways to, or underpin, such endpoints. We categorize the literature into four "components": people; places; products; and planet. People refers to social positions, interactions and networks creating well-being. Places are physical environments-built and natural-and the interests and policies shaping them. Products are commodities and commercial practices impacting population health. Planet places human health in the context of the 'Anthropocene.' These components interact in complex ways across global, regional, country and community levels as outlined in our heuristic.

CONCLUSION

The literature offers little critical reflection on why greater progress has not been made, or on the need to organise and resist the prevailing systems which perpetuate ill-health.

How to Build Healthy Societies: A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

As the Sustainable Development Goals deadline of 2030 draws near, greater attention is being given to health beyond the health sector, in other words, to the creation of healthy societies. However, action and reform in this area has not kept pace, in part due to a focus on narrower interventions and the lack of upstream action on health inequity. With an aim to guide action and political engagement for reform, we conducted a thematic analysis of concepts seeking to arrive at healthy societies.

METHODS

This paper drew on a qualitative thematic analysis of a purposive sample of 68 documents including political declarations, reports, peer reviewed literature and guidance published since 1974. Three independent reviewers extracted data to identify, discuss and critique public policy levers and 'enablers' of healthy societies, the "how."

RESULTS

The first lever concerned regulatory and fiscal measures. The second was intersectoral action. The final lever a shift in the global consensus around what signifies societal transformation and outcomes. The three enablers covered political leadership and accountability, popular mobilization and the generation and use of knowledge.

CONCLUSION

Documents focused largely on technical rather than political solutions. Even as the importance of political leadership was recognized, analysis of power was limited. Rights-based approaches were generally neglected as was assessing what worked or did not work to pull the levers or invest in the enablers. Frameworks typically failed to acknowledge or challenge prevailing ideologies, and did not seek to identify ways to hold or governments or corporations accountable for failures. Finally, ideas and approaches seem to recur again over the decades, without adding further nuance or analysis. This suggests a need for more upstream, critical and radical approaches to achieve healthy societies.

Nurses' lived experience of peacebuilding

Nursing has a unique opportunity to address issues of structural violence that contribute to poor health outcomes. Models for designing nursing care relative to the social determinants of health can be adapted from the discipline of peace studies and the phenomenon of peacebuilding. The aim of this qualitative study was to describe the lived experience of peacebuilding from the perspective of community or public health nurses. Interviews were conducted with eight participants. Attributes of the peacebuilder included fostering human relationships that value the inherent worth and dignity of others, nurturing a character of humility and moral courage, and contemplating the personal cost of engaging in prolonged processes of peacebuilding. Practices of peacebuilding included mediating conflict through multilayered processes, accompanying others to places of empowerment, and utilizing interdisciplinary teaching and learning to build capacity for change. Increasing an understanding of the lived experience of peacebuilding by nurses is relevant to nursing research, theory, and practice, and adds to a broader understanding of peacebuilding.

Anthropological perspectives on CKDnt in Mexico: time for a paradigm shift on the social determinants of health

In Mexico, the kidneys of individuals in poor and marginalized communities are failing with little warning and no explanation. Commonly referred to as chronic kidney disease of non-traditional origin (CKDnt), this new variant of kidney disease cannot be accounted for by conventional or discrete etiological explanations, but is instead understood to be a consequence of economic development, environmental degradation and precarious working and living conditions. Drawing on two interconnected ethnographic studies, and the intertwining problems of causation and care, this paper will (1) document the social conditions of disease emergence around Lake Chapala, Central Mexico, and (2) follow the haphazard routes kidney patients take to access resource-intensive biotechnical treatments. Its aim is to both challenge and reconceptualize social determinants as social relations in order to fully account for the profoundly contextual, temporal, and dynamic character of this condition, and to rethink opportunities for care and intervention.

The impact of social violence on HIV risk for women in Colombia: A concurrent mixed methods study

Gender, violence, and migration structurally impact health. The Venezuelan humanitarian crisis comprises the largest transnational migration in the history of the Americas. Colombia, a post-conflict country, is the primary recipient of Venezuelans. The Colombian context imposes high levels of violence on women across migration phases. There is little information on the relationship between violence and HIV risk in the region and how it impacts these groups. Evidence on how to approach the HIV response related to Venezuela's humanitarian crisis is lacking. Our study seeks to 1) understand how violence is associated with newly reported HIV/AIDS case rates for women in Colombian municipalities; and 2) describe how social violence impacts HIV risk, treatment, and prevention for Venezuelan migrant and refugee women undergoing transnational migration and resettlement in Colombia. We conducted a concurrent mixed-methods design. We used negative binomial models to explore associations between social violence proxied by Homicide Rates (HR) at the municipality level (n = 84). The also conducted 54 semi-structured interviews with Venezuelan migrant and refugee women and key informants in two Colombian cities to expand and describe contextual vulnerabilities to HIV risk, prevention and care related to violence. We found that newly reported HIV cases in women were 25% higher for every increase of 18 homicides per 100,000, after adjusting for covariates. Upon resettlement, participants cited armed actors' control, lack of government accountability, gender-based violence and stigmatization of HIV as sources of increased HIV risk for VMRW. These factors impose barriers to testing, treatment and care. Social violence in Colombian municipalities is associated with an increase in newly reported HIV/AIDS case rates in women. Violence hinders Venezuelan migrant and refugee women's access and engagement in available HIV prevention and treatment interventions.

Structural violence and the uncertainty of viral undetectability for African, Caribbean and Black people living with HIV in Canada: an institutional ethnography

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.

Structural competency in New Mexico: Moving outside of medical education

ABSTRACTIn 2019, the Doña Ana Wellness Institute (DAWI), Doña Ana County, New Mexico's health council, sponsored two trainings in structural competency by the Structural Competency Working Group. One focused on health care professionals and learners; the other focused on government, non-profit organisations, and elected officials. DAWI and New Mexico Human Services Department (HSD) representatives attended the trainings and identified the structural competency model as useful for the health equity work both groups were already engaging. These trainings provided the foundation for DAWI and HSD to develop additional trainings, programmes, and curricula founded on structural competency and focused on supporting health equity work.This article describes how DAWI and HSD used the structural competency framework to deepen our work, including how we have expanded the concept beyond its original orientation to support strategic planning, improve communication, and build structurally competent communities. We illustrate how the framework strengthened our existing community and state work and how we adapted the model to better fit our work. Adaptations included changes in language, the use of the lived experiences of organisation members as a foundation for structural competency education, and a recognition that policy work happens at multiple levels and in multiple ways for organisations.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift

INTRODUCTION

To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities.

AIMS AND METHODS

In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020.

RESULTS

Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process.

CONCLUSIONS

Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity.

IMPLICATIONS

Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Structural violence: An evolutionary concept analysis

AIMS

To enhance conceptual clarity and interdisciplinary understanding of structural violence, and to illuminate its implications for contemporary social justice and health equity research, by: (1) synthesizing scholarly literature pertaining to structural violence and health; (2) defining its key attributes, antecedents, consequences and characteristics; (3) contextually situating this phenomenon over time and across disciplines.

DESIGN

A comprehensive review of scholarly health literature pertaining to 'structural violence' or its surrogate term 'structural determinants of health' was guided by a Research and Education Librarian.

DATA SOURCES

In November 2019 and again in April 2021, CINAHL, Embase, Global Health, Medline, PsycINFO, PubMed and Scopus electronic databases were searched for peer-reviewed articles that described structural violence in the context of health. Of the 238 unique records identified, 32 articles were selected for inclusion and comprise the review sample.

REVIEW METHODS

Using Beth Rodgers' evolutionary concept analysis method, articles were comparatively analysed to identify key attributes, antecedents and consequences associated with the concept's use in health research.

RESULTS

The five interrelated attributes characterizing structural violence are: power, marginality, oppression, adversity and trauma. Hegemonic social, cultural, economic and political systems serve as antecedents, whilst the consequences of structural violence can be broadly classified as health inequity, injustice and indignity, and social disorganization.

CONCLUSION

This analysis contributes to conceptual clarity and mutual understanding of the usage, application and significance of structural violence across health disciplines and provides a strong foundation for continued concept development and operationalization. Further research is needed to substantiate the relationship between structural violence and health inequity.

The Need for Community-Responsive and Flexible Sex Ed for Historically Marginalized Youth

Introduction

When it is offered, sexuality education in the USA is far from standardized. While studies have explored differences in delivery and type of sexuality education across the USA, sexual and reproductive health inequities persist among historically marginalized groups (Latino/a/x, Black, African American, LGBTQ +). There is a critical need to better understand the systemic barriers to receiving effective sexuality education in these communities.

Methods

Participatory research methods were used in working with a community advisory board (CAB)-consisting of emerging adults and service providers from community-based organizations (CBOs) serving youth-to examine how structural barriers contribute to adolescent sexual and reproductive health (ASRH) inequities in Massachusetts. CAB meetings and semi-structured interviews were conducted in the cities of Springfield (n = 14) and Lynn (n = 9) between December 2020 and May 2021.

Results

Inflexible funding guidelines, a related evidence-based curricular mandate, and a lack of community-responsive sexuality education fail to meet the sexual and reproductive health (SRH) needs of these youth.

Conclusions

Current evidence-based mandates must be revisited to improve young people's access to quality sexuality information in public schools. To guarantee sexuality education curricula is centered in the context of the community and population in which it is implemented, collaboration between youth-serving CBOs and school districts could improve students' overall experience and social-emotional growth by providing comprehensive, positive, and community-responsive curricula.

Policy Implications

Funders and programming should prioritize community responsiveness by financially supporting and developing and/or adapting evidence-based curricula to better match the community's needs, which can be completed through culture-centered training and community-based partnership.

COVID-19 violence and the structural determinants of death: Canada's seasonal agricultural worker programme

The Seasonal Agricultural Worker Program (SAWP) is a managed migration programme that aims to fill labour shortages in Canada's agricultural industry with Black and Brown workers from the global South. For decades, migrant workers, scholars, and advocate groups have called for fundamental changes to address power imbalances produced by the design of the SAWP. The continued operation of the SAWP during the COVID-19 pandemic has intensified the underlying structural violence that migrant labourers experience. Analysing the SAWP as a case study in how globalised labour processes dehumanise and make workers disposable, we argue that it is one component in a web of social and structural factors rooted in colonialism and racial capitalism, constituting the structural determinants of death. Whereas the structural determinants of health point to health 'inequities' and 'disparities', we advance the concept of structural determinants of death to politicise the numerous and multidimensional forms of violence embedded within state policy and to shed light on their beneficiaries. In doing so, we detail how policies can diminish the agency necessary to avoid death in deadly conditions and, specifically, draw attention to the preventable suffering and death perpetuated by the SAWP.

'It All Kind of Links Really': Young People's Perspectives on the Relationship between Socioeconomic Circumstances and Health

Meaningful inclusion of young people's perceptions and experiences of inequalities is argued to be critical in the development of pro-equity policies. Our study explored young people's perceptions of what influences their opportunities to be healthy within their local area and their understandings of health inequalities. Three interlinked qualitative focus group discussions, each lasting 90 to 100 min, with the same six groups of young people (n = 42) aged 13-21, were conducted between February and June 2021. Participants were recruited from six youth groups in areas of high deprivation across three geographical locations in England (South Yorkshire, the North East and London). Our study demonstrates that young people understand that health inequalities are generated by social determinants of health, which in turn influence behaviours. They highlight a complex interweaving of pathways between social determinants and health outcomes. However, they do not tend to think in terms of the social determinants and their distribution as resulting from the power and influence of those who create and benefit from health and social inequalities. An informed understanding of the causes of health inequalities, influenced by their own unique generational experiences, is important to help young people contribute to the development of pro-equity policies of the future.

Desperately seeking reductions in health inequalities in Canada: Polemics and anger mobilization as the way forward?

Progress in reducing health inequalities through public policy action is difficult in nations identified as liberal welfare states. In Canada, as elsewhere, researchers and advocates provide governing authorities with empirical findings on the sources of health inequalities and document the lived experiences of those encountering these adverse health outcomes with the hope of provoking public policy action. However, critical analysis of the societal structures and processes that make improving the sources of health inequalities difficult-the quality and distribution of living and working conditions, that is the social determinants of health-identifies limitations in these approaches. Within this latter critical tradition, we consider-using household food insecurity in Canada as an illustration-how polemics and anger mobilization, usually absent in health inequalities research and advocacy-could force Canadian governing authorities to reduce health inequalities through public policy action. We explore the potential of using high valence terms such as structural violence, social death and social murder, which make explicit the adverse outcomes of health-threatening public policy to force government action. We conclude by outlining the potential benefits and threats posed by polemics and anger mobilization as means of promoting health equity.

Structural Violence and Health-Related Outcomes in Europe: A Descriptive Systematic Review

In recent years, there has been a revival of the term “structural violence (SV)” which was coined by Johan Galtung in the 1960s in the context of Peace Studies. “Structural violence” refers to social structures—economic, legal, political, religious, and cultural—that prevent individuals, groups and societies from reaching their full potential. In the European context, very few studies have investigated health and well-being using an SV perspective. Therefore, this paper sought to systematically and descriptively review studies that used an SV framework to examine health-related outcomes across European countries. The review included two studies each from Spain and France, one each from the UK, Ukraine and Russia, and another study including the three countries Sweden, Portugal and Germany. With the exception of one mixed-method study, the studies used a qualitative design. Furthermore, the eight studies in the review used different conceptualizations of SV, which indicates the complexity of using SV as a concept in public health in the European context. Future research that attempts to identify and standardize measures of SV is needed; the knowledge gained is hoped to inform appropriate interventions aiming to reduce the effects of SV on population health.