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BERKOWITZ SETHA. Multisector Collaboration vs. Social Democracy for Addressing Social Determinants of Health. Milbank Q 2024; 102:280-301. [PMID: 38156764 PMCID: PMC11176409 DOI: 10.1111/1468-0009.12685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/13/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Policy Points Multisector collaboration, the dominant approach for responding to health harms created by adverse social conditions, involves collaboration among health care insurers, health care systems, and social services organizations. Social democracy, an underused alternative, seeks to use government policy to shape the civil (e.g., civil rights), political (e.g., voting rights), and economic (e.g., labor market institutions, property rights, and the tax-and-transfer system) institutions that produce health. Multisector collaboration may not achieve its goals, both because the collaborations are difficult to accomplish and because it does not seek to transform social conditions, only to mitigate their harms. Social democracy requires political contestation but has greater potential to improve population health and health equity.
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HELLER JONATHANC, GIVENS MARJORYL, JOHNSON SHERIP, KINDIG DAVIDA. Keeping It Political and Powerful: Defining the Structural Determinants of Health. Milbank Q 2024; 102:351-366. [PMID: 38363858 PMCID: PMC11176401 DOI: 10.1111/1468-0009.12695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/10/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024] Open
Abstract
Policy Points The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work-implicitly and explicitly-to maintain their advantage by reinforcing or modifying these rules. This theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health's role in shifting power relations and engaging politically, especially in its policy work. Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.
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Affiliation(s)
- JONATHAN C. HELLER
- These authors contributed equally to this work
- Population Health InstituteUniversity of Wisconsin
- National Collaborating Centre for Determinants of HealthSaint Francis Xavier University
| | - MARJORY L. GIVENS
- These authors contributed equally to this work
- Population Health InstituteUniversity of Wisconsin
| | | | - DAVID A. KINDIG
- Population Health Sciences, Population Health Institute, School of Medicine and Public HealthUniversity of Wisconsin–Madison
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Simon-Ortiz S, Bilick S, Frey M, Gould S, Long C, Waugh E, Farhang L. Community Power-Building Groups And Public Health NGOs: Reimagining Public Health Advocacy. Health Aff (Millwood) 2024; 43:798-804. [PMID: 38830166 DOI: 10.1377/hlthaff.2024.00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Public health frameworks have grappled with the inequitable distribution of power as a driver of the social conditions that determine health. However, these frameworks have not adequately considered building community power as a strategy to shift the distribution of power. Community power-building organizations build and organize a base of affected people to take collective action to transform their material conditions, using advocacy and other tactics. We conducted qualitative interviews with representatives of twenty-two national nongovernmental public health organizations (public health NGOs) and thirteen community power-building organizations to explore the nature and potential of partnerships between public health and community power-building organizations. Our findings suggest ways to close advocacy gaps within the public health ecosystem and ways in which public health can strategically leverage its power, resources, and expertise to support social justice campaigns and movements.
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Affiliation(s)
| | | | - Maddy Frey
- Maddy Frey, Frey Evaluation, LLC, Atlanta, Georgia
| | | | | | - Emma Waugh
- Emma Waugh, Hoehn Public Health Consulting, LLC, Atlanta, Georgia
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Gollust SE, Gansen C, Fowler EF, Moore ST, Nagler RH. Polarized Perspectives on Health Equity: Results from a Nationally Representative Survey on US Public Perceptions of COVID-19 Disparities in 2023. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2024; 49:403-427. [PMID: 37987174 DOI: 10.1215/03616878-11066304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Republicans and Democrats responded to the COVID-19 pandemic in starkly different ways, from their attitudes in 2020 about whether the virus posed a threat to whether the pandemic ended in 2023. The consequences of COVID-19 for health equity have been a central concern in public health, and the concept of health equity has also been beset by partisan polarization. In this article, the authors present and discuss nationally representative survey data from 2023 on US public perceptions of disparities in COVID-19 mortality (building on a previous multiwave survey effort) as well as causal attributions for racial disparities, the contribution of structural racism, and broader attitudes about public health authority. The authors find anticipated gulfs in perspectives between Democrats on the one hand and independents and Republicans on the other. The results offer a somewhat pessimistic view of the likelihood of finding common ground in how the general public understands health inequities or the role of structural racism in perpetuating them. However, the authors show that those who acknowledge racial disparities in COVID-19 are more likely to support state public health authority to act in response to other infectious disease threats. The authors explore the implications of these public opinion data for advocacy, communication, and future needed research.
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Matheson A, Wehipeihana N, Gray R, Walton M, Uia T, Lindberg K, Shanthakumar M, Lopez MI, Reidy J, Firestone R, Ellison-Loschmann L. Building a systems-thinking community workforce to scale action on determinants of health in New Zealand. Health Place 2024; 87:103255. [PMID: 38710122 DOI: 10.1016/j.healthplace.2024.103255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Abstract
This article describes findings from the evaluation of Healthy Families NZ (HFNZ), an equity-driven, place-based community health initiative. Implemented in nine diverse communities across New Zealand, HFNZ aims to strengthen the systems that can improve health and well-being. Findings highlight local needs and priorities including the social mechanisms important for reorienting health and policy systems towards place-based communities. Lessons encompass the importance of local lived experience in putting evidence into practice; the strength of acting with systems in mind; the need for relational, learning, intentional, and well-resourced community organisation; examples of how to foster place-based 'community-up' leadership; and how to enable responsiveness between communities and local and national policy systems. A reconceptualisation of scaling in the context of complexity and systems change is offered, which recognises that relationships and agency are key to making progress on the determinants of health.
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Affiliation(s)
- Anna Matheson
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand.
| | - Nan Wehipeihana
- Weaving Insights, PO Box 147, Levin 5540, Horowhenua, New Zealand
| | - Rebecca Gray
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Mat Walton
- Institute of Environmental Science and Research Limited (ESR), Kenepuru Science Centre: 34 Kenepuru Drive, Kenepuru, Porirua 5022, PO Box 50348, Porirua 5240, New Zealand
| | - Tali Uia
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Kirstin Lindberg
- Environmental Health Intelligence New Zealand, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
| | - Mathu Shanthakumar
- Environmental Health Intelligence New Zealand, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
| | - Maite Irurzun Lopez
- Health Services Research Centre, Te Herenga Waka, Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Johanna Reidy
- School of Health, Te Herenga Waka - Victoria University of Wellington, Kelburn 6012, Wellington, New Zealand
| | - Riz Firestone
- Centre for Hauora and Health, Massey University, Wallace Street, Mount Cook, Wellington 6021, New Zealand
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Baciu AB, Martinez RM. Revisiting the IOM Reports and Envisioning a Promising Future for Public Health. Am J Public Health 2024; 114:495-500. [PMID: 38598765 PMCID: PMC11008293 DOI: 10.2105/ajph.2024.307584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Two public health reports from the National Academies of Sciences, Engineering, and Medicine published in 1988 and 2003 by the Institute of Medicine continue to resonate. The COVID-19 pandemic highlighted the need for a robust and adequately funded public health system that has political and public support as well as strong connections to health care and other sectors. However, a spate of recent assessments of the nation's public health infrastructure shows continuing gaps in funding, workforce, capacity, and other dimensions. There are reasons for optimism and opportunities for progress in public health in the third decade of the 21st century. There is great promise in cross-sector partnerships and in embracing the "public" in public health by building power with communities in health improvement efforts and in decision-making. (Am J Public Health. 2024;114(5):495-500. https://doi.org/10.2105/AJPH.2024.307584).
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Affiliation(s)
- Alina B Baciu
- Alina B. Baciu and Rose Marie Martinez are with the Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Rose Marie Martinez
- Alina B. Baciu and Rose Marie Martinez are with the Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, Washington, DC
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Beck AF, Seid M, McDowell KM, Udoko M, Cronin SC, Makrozahopoulos D, Powers T, Fairbanks S, Prideaux J, Vaughn LM, Hente E, Thurmond S, Unaka NI. Building a regional pediatric asthma learning health system in support of optimal, equitable outcomes. Learn Health Syst 2024; 8:e10403. [PMID: 38633017 PMCID: PMC11019385 DOI: 10.1002/lrh2.10403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/18/2023] [Accepted: 11/27/2023] [Indexed: 04/19/2024] Open
Abstract
Introduction Asthma is characterized by preventable morbidity, cost, and inequity. We sought to build an Asthma Learning Health System (ALHS) to coordinate regional pediatric asthma improvement activities. Methods We generated quantitative and qualitative insights pertinent to a better, more equitable care delivery system. We used electronic health record data to calculate asthma hospitalization rates for youth in our region. We completed an "environmental scan" to catalog the breadth of asthma-related efforts occurring in our children's hospital and across the region. We supplemented the scan with group-level assessments and focus groups with parents, clinicians, and community partners. We used insights from this descriptive epidemiology to inform the definition of shared aims, drivers, measures, and prototype interventions. Results Greater Cincinnati's youth are hospitalized for asthma at a rate three times greater than the U.S. average. Black youth are hospitalized at a rate five times greater than non-Black youth. Certain neighborhoods bear the disproportionate burden of asthma morbidity. Across Cincinnati, there are many asthma-relevant activities that seek to confront this morbidity; however, efforts are largely disconnected. Qualitative insights highlighted the importance of cross-sector coordination, evidence-based acute and preventive care, healthy homes and neighborhoods, and accountability. These insights also led to a shared, regional aim: to equitably reduce asthma-related hospitalizations. Early interventions have included population-level pattern recognition, multidisciplinary asthma action huddles, and enhanced social needs screening and response. Conclusion Learning health system methods are uniquely suited to asthma's complexity. Our nascent ALHS provides a scaffold atop which we can pursue better, more equitable regional asthma outcomes.
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Affiliation(s)
- Andrew F. Beck
- Division of General & Community PediatricsCincinnati Children'sCincinnatiOhioUSA
- Division of Hospital MedicineCincinnati Children'sCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Michael Fisher Child Health Equity CenterCincinnati Children'sCincinnatiOhioUSA
- Office of Population HealthCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Michael Seid
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Karen M. McDowell
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Mfonobong Udoko
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Susan C. Cronin
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | | | - Tricia Powers
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
| | - Sonja Fairbanks
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
| | - Jonelle Prideaux
- Division of Emergency MedicineCincinnati Children'sCincinnatiOhioUSA
- Qualitative Methods & Analysis CollaborativeCincinnati Children'sCincinnatiOhioUSA
| | - Lisa M. Vaughn
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Emergency MedicineCincinnati Children'sCincinnatiOhioUSA
- Qualitative Methods & Analysis CollaborativeCincinnati Children'sCincinnatiOhioUSA
- Criminal Justice, & Human ServicesUniversity of Cincinnati College of EducationCincinnatiOhioUSA
| | | | - Sophia Thurmond
- Department of Information ServicesCincinnati Children'sCincinnatiOhioUSA
| | - Ndidi I. Unaka
- Division of Hospital MedicineCincinnati Children'sCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Michael Fisher Child Health Equity CenterCincinnati Children'sCincinnatiOhioUSA
- Office of Population HealthCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Abstract
Racial disparities in health are among the most disconcerting forms of inequity in the United States. Divergent health outcomes between Americans racialized as White and those racialized as Black, Latinx, and Indigenous do not stem from biological or genetic differences. To the contrary, "race" comes to have concrete consequences through social, economic, and political systems. Yet the political contours of health equity remain especially understudied. This article places the politics of health equity in the foreground through the lens of housing, a critical determinant of health. Drawing on in-depth qualitative evidence rooted in the experiences of tenants who confront health-threatening housing conditions, I examine how people within racially and economically marginalized communities organize to build political power in response to those conditions. By charting how tenants navigate state and local political processes, I demonstrate the possibilities for organized tenants to wield power in ways that help advance health equity in the face of structural racism.
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Heller JC, Fleming PJ, Petteway RJ, Givens M, Pollack Porter KM. Power Up: A Call for Public Health to Recognize, Analyze, and Shift the Balance in Power Relations to Advance Health and Racial Equity. Am J Public Health 2023; 113:1079-1082. [PMID: 37535894 PMCID: PMC10484127 DOI: 10.2105/ajph.2023.307380] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Jonathan C Heller
- Jonathan C. Heller is with the University of Wisconsin Population Health Institute, Madison, WI, and the National Collaborating Centre for Determinants of Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada. Paul J. Fleming is with the University of Michigan School of Public Health, Ann Arbor, MI. Ryan J. Petteway is with the Oregon Health and Science University‒Portland State University School of Public Health, Portland, OR. Marjory Givens is with the University of Wisconsin Population Health Institute. Keshia M. Pollack Porter is with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Paul J Fleming
- Jonathan C. Heller is with the University of Wisconsin Population Health Institute, Madison, WI, and the National Collaborating Centre for Determinants of Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada. Paul J. Fleming is with the University of Michigan School of Public Health, Ann Arbor, MI. Ryan J. Petteway is with the Oregon Health and Science University‒Portland State University School of Public Health, Portland, OR. Marjory Givens is with the University of Wisconsin Population Health Institute. Keshia M. Pollack Porter is with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ryan J Petteway
- Jonathan C. Heller is with the University of Wisconsin Population Health Institute, Madison, WI, and the National Collaborating Centre for Determinants of Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada. Paul J. Fleming is with the University of Michigan School of Public Health, Ann Arbor, MI. Ryan J. Petteway is with the Oregon Health and Science University‒Portland State University School of Public Health, Portland, OR. Marjory Givens is with the University of Wisconsin Population Health Institute. Keshia M. Pollack Porter is with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marjory Givens
- Jonathan C. Heller is with the University of Wisconsin Population Health Institute, Madison, WI, and the National Collaborating Centre for Determinants of Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada. Paul J. Fleming is with the University of Michigan School of Public Health, Ann Arbor, MI. Ryan J. Petteway is with the Oregon Health and Science University‒Portland State University School of Public Health, Portland, OR. Marjory Givens is with the University of Wisconsin Population Health Institute. Keshia M. Pollack Porter is with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Keshia M Pollack Porter
- Jonathan C. Heller is with the University of Wisconsin Population Health Institute, Madison, WI, and the National Collaborating Centre for Determinants of Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada. Paul J. Fleming is with the University of Michigan School of Public Health, Ann Arbor, MI. Ryan J. Petteway is with the Oregon Health and Science University‒Portland State University School of Public Health, Portland, OR. Marjory Givens is with the University of Wisconsin Population Health Institute. Keshia M. Pollack Porter is with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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