Getting serious about the social determinants of health: new directions for public health workers

Insights into local health and wellbeing policy process in Australia

To investigate factors that enable or challenge the initiation and actioning of health and wellbeing policy in Australian local governments using political science frameworks. An online survey was distributed to staff and elected members of Australian local governments. The survey sought responses to a range of variables as informed by political science frameworks. Data were analysed using descriptive statistics and results were compared between local governments of different geographical sizes and locations using Kruskal-Wallis non-parametric testing. There were 1825 survey responses, including 243 CEOs, representing 45% of Australian local governments. Enablers for local government policy initiation and action included the high priority given to health and wellbeing (44%), local leadership (56%) and an organizational (70%) and personal obligation (68%) to the community to act. Less true is a favourable legislative environment (33%), leadership from higher levels of government (29%) and sufficient financial capacity (22%). Cities are better positioned to initiate and action health policy, regardless of the broader legislative environment. Health and wellbeing is a high priority for Australian local governments, despite lack of funding and limited lobbying and support from other sectors and higher levels of government. The insights from political science frameworks assist to understand the policy process, including the interrelatedness of enablers and challenges to initiating and actioning health and wellbeing policy. Further understanding the policy drivers would support practitioners and researchers advocating to influence local health and wellbeing policy.

Better Choice, Better Health? Social Integration and Health Inequality among International Migrants in Hangzhou, China

The aim of this study is to investigate the impact of social integration and socioeconomic status on immigrant health in China. Taking the framework of social determinants of health (SDH) as the theoretical starting point, this paper uses the Hangzhou sample of the 2018 Survey of Foreigners in China (SFRC2018) to explore two core factors affecting the health inequality of international migrants in China: the level of social integration following settlement, and socioeconomic status before and after coming to China. The results show that having a formal educational experience in China helped improve both the self-rated health status and self-assessed change in health of international migrants; that the socioeconomic status of an emigrant's home country affected self-rated health; and that the self-assessed change in health of immigrants from developing countries was significantly higher than those from developed countries. This study concludes that the health inequalities of immigrant populations in China must be understood in the context of China's specific healthcare system and treatment structure.

No Equity, No Triple Aim: Strategic Proposals to Advance Health Equity in a Volatile Policy Environment

Health professionals, including social workers, community health workers, public health workers, and licensed health care providers, share common interests and responsibilities in promoting health equity and improving social determinants of health-the conditions in which people live, work, play, and learn. We summarize the underlying causes of health inequity and comparatively poor health outcomes in the United States. We describe barriers to realizing the hope embedded in the 2010 Patient Protection and Affordable Care Act, that moving away from fee-for-service payments will naturally drive care upstream as providers respond to greater financial risk by undertaking greater prevention efforts for the health of their patients. We assert that health equity should serve as the guiding framework for achieving the Triple Aim of health care reform and outline practical opportunities for improving care and promoting stronger efforts to address social determinants of health. These proposals include developing a dashboard of measures to assist providers committed to health equity and community-based prevention and to promote institutional accountability for addressing socioeconomic factors that influence health.

Taking stock of the social determinants of health: A scoping review

BACKGROUND

In recent decades, the social determinants of health (SDOH) has gained increasing prominence as a foundational concept for population and public health in academic literature and policy documents, internationally. However, alongside its widespread dissemination, and in light of multiple conceptual models, lists, and frameworks, some dilution and confusion is apparent. This scoping review represents an attempt to take stock of SDOH literature in the context of contemporary population and public health.

METHODS

We conducted a scoping review to synthesize and map SDOH literature, informed by the methods of Arksey and O'Malley (2005). We searched 5 academic and 3 grey literature databases for "social determinants of health" and "population health" or "public health" or "health promotion," published 2004-2014. We also conducted a search on "inequity" or "inequality" or "disparity" or "social gradient" and "Canad*" to ensure that we captured articles where this language was used to discuss the SDOH. We included articles that discussed SDOH in depth, either explicitly or in implicit but nuanced ways. We hand-searched reference lists to further identify relevant articles.

FINDINGS

Our synthesis of 108 articles showed wide variation by study setting, target audience, and geographic scope, with most articles published in an academic setting, by Canadian authors, for policy-maker audiences. SDOH were communicated by authors as a list, model, or story; each with strengths and weaknesses. Thematic analysis identified one theme: health equity as an overarching and binding concept to the SDOH. Health equity was understood in different ways with implications for action on the SDOH.

CONCLUSIONS

Among the vast SDOH literature, there is a need to identify and clearly articulate the essence and implications of the SDOH concept. We recommend that authors be intentional in their efforts to present and discuss SDOH to ensure that they speak to its foundational concept of health equity.

Bridging the silos in HIV and Hepatitis C prevention: a cross-provincial qualitative study

Objectives

The Our Youth Our Response (OYOR) study explored the scope and accessibility of existing youth-oriented human immunodeficiency virus (HIV) and Hepatitis C (HCV) prevention in Atlantic Canada.

Methods

A cross-provincial, qualitative population health and gender-based analytic approach was used in this study. Four hundred and twenty-five documents were part of the initial scoping review, while 47 in-depth interviews across youth-relevant sectors were undertaken to explore the perceptions related to current approaches to youth-oriented HIV/HCV prevention policies and programs. The study also conducted focus group discussions with 21 key informants aimed at identifying strategies to address the challenges identified from the interview data.

Results

Five overarching themes emerged from our triangulated data in relation to the present state of youth-related HIV/HCV prevention. These included: inter-organizational and intersectoral collaboration; youth engagement; access to testing; harm reduction; and education.

Conclusions

Our findings will assist in informing the next generation for HIV/HCV prevention aimed at youth. Specifically, the results indicate that future prevention initiatives should support the use of intersectoral collaboration, gender-based approaches, and HIV/HCV testing innovation to help de-stigmatize prevention efforts.

The influence of newborn early literacy intervention programs in three canadian provinces

Low levels of literacy in early childhood can have lasting effects on children's educational and intellectual development. Many countries have implemented newborn literacy programs designed to teach parents pre-literacy promoting activities to share with their children. We conducted 2 quasi-experimental studies using 1) a pre-test/post-test design and 2) a non-equivalent control group design to examine the effect of newborn literacy programs on parents' self-reported literacy intentions/behaviors, values toward literacy, and parent-child interactions. Parents were recruited from 3 provinces, 2 with newborn literacy programs (intervention) and 1 without (control). Parents in the intervention group completed prenatal and postnatal (after participation in program) questionnaires. Parents in the control group completed 1 questionnaire. Questionnaires were designed to capture parents' literacy intentions (prenatal), behaviors (postnatal), values, and parent-child interactions (postnatal). A total of 98 parents were included in study one and 174 were included in study two. Parents' self-reported prenatal intentions and values were higher than their postnatal behaviors and values. Parents in the intervention group exhibited higher literacy behaviors and values and greater enjoyment reading to their children than parents in the control group, though they also reported reading to their children less frequently. Parents in the intervention group had significantly higher Positive Interactive scores than controls. Overall, we found participation in newborn literacy programs positively impacted parenting behaviors and attitudes. Lower postnatal within-group scores (intentions and values versus behaviors and values) may have been the result of participants' high expectations. Given our findings, we recommend that these programs continue.

Manifestations of integrated public health policy in Dutch municipalities

Integrated public health policy (IPHP) aims at integrating health considerations into policies of other sectors. Since the limited empirical evidence available may hamper its further development, we systematically analysed empirical manifestations of IPHP, by placing policy strategies along a continuum of less-to-more policy integration, going from intersectoral action (IA) to healthy public policy (HPP) to health in all policies (HiAP). Our case study included 34 municipal projects of the Dutch Gezonde Slagkracht Programme (2009-15), which supports the development and implementation of IPHP on overweight, alcohol and drug abuse, and smoking. Our content analysis of project application forms and interviews with all project leaders used a framework approach involving the policy strategies and the following policy variables: initiator, actors, policy goals, determinants and policy instruments. Most projects showed a combination of policy strategies. However, manifestations of IPHP in overweight projects predominantly involved IA. More policy integration was apparent in alcohol/drugs projects (HPP) and in all-theme projects (HiAP). More policy integration was related to broad goal definitions, which allowed for the involvement of actors representing several policy sectors. This enabled the implementation of a mix of policy instruments. Determinants of health were not explicitly used as a starting point of the policy process. If a policy problem justifies policy integration beyond IA, it might be helpful to start from the determinants of health (epidemiological reality), systematically transform them into policy (policy reality) and set broad policy goals, since this gives actors from other sectors the opportunity to participate.

Reflections on the framing of 'health equity' in the National Primary Health Care Strategic Framework: a cause for celebration or concern?

ISSUE ADDRESSED

There has been a growing national and global focus on the need to address social determinants of health to better achieve equitable health outcomes. In Australia, this focus is now being embedded into state, territory and Commonwealth government health policies. In this paper I use the National Primary Health Care Strategic Framework as a case study to examine the way in which 'health equity' and other related terms have been framed within a current national health policy context.

DISCUSSION

Using a critically reflective approach, I argue that primary health care and health promotion professionals need to capitalise on the inclusion of terms such as 'action on social determinants of health', 'health equity' and 'reducing inequity' through emerging national health policies, such as the National Primary Health Care Strategic Framework. Yet, there is also a need to proceed with caution. The way in which these terms are framed appears to deviate from the principles, values and ideologies on which they are historically based. The implications for contemporary health promotion practice in Australia are discussed.

CONCLUSIONS

Primary health care and health promotion professionals working in both policy and practice contexts are encouraged to engage in critical reflective practice when interpreting and considering the implementation requirements of national health policies that incorporate a health equity focus. So what? To build health equity in Australia, primary health care and health promotion professionals will be required to engage in the skilful reframing of current primary health care policy discourses relating to health equity during health promotion planning, implementation and evaluation processes.

Promoting Health Equity Research: Insights from a Canadian Initiative

In 2002 the Canadian Institutes of Health Research launched a national initiative to promote health equity research reflecting the World Health Organization imperative of investment in health equity research. Funded researchers and teams have investigated health disparities faced by vulnerable populations, analyzed interactions of health determinants, and tested innovative interventions. Strategies for building research capacity have supported students, postdoctoral fellows, new investigators, and interdisciplinary research teams. Partnerships have been created with 10 national and 7 international organizations. Strategies used to secure and sustain this research initiative could be adapted to other contexts. Nurse scholars led the launch and have sustained the legacy of this national research initiative. Moreover, nurse researchers and research trainees, supported by the initiative, have contributed to the expansion and translation of the health equity knowledge base.

Perceptions of the social determinants of health by two groups more and less affiliated with public health in Canada

BACKGROUND

Despite strong academic recognition of the SDOH both in Canada and internationally, acknowledgement and uptake of the SDOH in health policy and public consciousness have remained weak. This paper aims to discern reasons for limited action on the SDOH by examining the perceptions of the SDOH held by two groups more and less affiliated with public health in Canada.We conducted formal consultation with group members on their interpretation of the SDOH and their thoughts on the nature and basis of differences between those more and less aligned with the SDOH as a basis for action. Thematic analysis was used to evaluate the views of the two groups.

FINDINGS

Group 1 (community/public health workers) felt overwhelmed when confronted with questions regarding action on the SDOH within the context of their professional lives. They suggested an expanded list of health determinants that included factors such as voluntarism and happiness, transcending traditional notions of "root causes." Furthermore, they did not articulate value-based reasons why others would oppose the SDOH; rather, in line with their professional roles, they adopted a value-neutral and pragmatic approach to working to improve health. Group 2 (child and youth advocacy organization members) seemed rooted in the 1986 Ottawa Charter for Health Promotion framework, with their recommendations aligned with strategies such as building healthy public policy and reorienting health services. Neither group made reference to issues of social justice or inequity when they made suggestions for improving health.

CONCLUSIONS

We found that two groups with different affiliations to formal public health could discuss the SDOH without acknowledging the inequitable distribution of power and resources that lies at its root. We also found that those working in public health had difficulty moving beyond individual actions that they or their clients could take to improve health. For a group more focused on advocacy than direct service provision, the Ottawa Charter framework seemed more easily suited to their recommendations for action than suggesting actions that would address the SDOH. Our findings indicate that there remains work to be done in terms of translating the SDOH concept into action in Canada.

Making the invisible visible: are health social workers addressing the social determinants of health?

This study explored the ways in which health social workers (HSW) address the social determinants of health (SDH) within their social work practice. Social workers (n = 54) employed at major hospitals across Toronto had many years of practice in health care (M = 11 years; SD = 10.32) and indicated that SDH were a top priority in their daily work; with 98% intentionally intervening with at least one and 91% attending to three or more. Health care services were most often addressed (92%), followed by housing (72%), disability (79%), income (72%), and employment security (70%). Few HSW were tackling racism, Aboriginal status, gender, or social exclusion in their daily practice.

[Current and future competencies for public health professionals]

OBJECTIVES

To identify current and future competencies (managers and technicians) for public health professionals in Catalonia (Spain).

METHODS

Qualitative research with a phenomenological approach. Between November 2009 and February 2010, 31 semistructured interviews were completed with public health professionals working in Catalonia. We purposely used a theoretical sample to include the maximum multiplicity of discourses. We conducted a thematic content analysis.

RESULTS

We obtained a wide range of current professional competencies, as well as those required for the future, classified according to professional profile. The participants highlighted transversal competencies, such as the importance of sharing a general theoretical framework of the discipline and the institution. Among the most frequently reported competencies were knowledge management, communication skills, teamwork, multidisciplinary and intersectoral orientation, legal knowledge, computer skills and languages, particularly English. It was also important for individual professionals to have specific skills in their areas of activity. In terms of differences between managers and technicians, the study showed that technicians prioritize management skills concerning human and material resources, while managers emphasize organizational and professional public health expertise.

CONCLUSIONS

There is a need for transversal and specific competencies in distinct areas. Public health is a multidisciplinary field, which collaborates with a wide range of professionals and organizations.

Latest OECD figures confirm Canada as a public health laggard

Despite the Canadian public health community's commitments to promoting public policy that supports health, evidence indicates that Canada's public health picture continues to decline. This may be due in part to the failure of public health agencies and local public health units to engage in public policy advocacy and public education about the social determinants of health. Examples of such activities by local public health units are now available and provide a model for such activity.

Social determinants of health in Canada: are healthy living initiatives there yet? A policy analysis

INTRODUCTION

Preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in British Columbia and Ontario for combating chronic diseases. What has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.

METHODS

Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs).

RESULTS

60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5% of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15% were structure-based. Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.

CONCLUSIONS

The paucity of initiatives in British Columbia and Ontario that address healthy eating and active living through action on the social determinants of health is problematic. In the context of Canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. It is necessary that health be seen for what it is: a political matter. As such, the health sector needs to take a more political approach in finding solutions for health inequities.

Moving Canadian governmental policies beyond a focus on individual lifestyle: some insights from complexity and critical theories

This paper explores why Canadian government policies, particularly those related to obesity, are 'stuck' at promoting individual lifestyle change. Key concepts within complexity and critical theories are considered a basis for understanding the continued emphasis on lifestyle factors in spite of strong evidence indicating that a change in the environment and conditions of poverty isare needed to tackle obesity. Opportunities to get 'unstuck' from individual-level lifestyle interventions are also suggested by critical concepts found within these two theories, although getting 'unstuck' will also require cross-sectoral collective action. Our discussion focuses on the Canadian context but will undoubtedly be relevant to other countries, where health promoters and others engage in similar struggles for fundamental government policy change.

'Health equity through action on the social determinants of health': taking up the challenge in nursing

Reducing health inequities is a priority issue in Canada and worldwide. In this paper, we argue that nursing has a clear mandate to ensure access to health and health-care by providing sensitive empowering care to those experiencing inequities and working to change underlying social conditions that result in and perpetuate health inequities. We identify key dimensions of the concept of health (in)equities and identify recommendations to reduce inequities advanced in key global and Canadian documents. Using these documents as context, we advocate a 'critical caring approach' that will assist nurses to understand the social, political, economic and historical context of health inequities and to tackle these inequities through policy advocacy. Numerous societal barriers as well as constraints within the nursing profession must be acknowledged and addressed. We offer recommendations related to nursing practice, education and research to move forward the agenda of reducing health inequities through action on the social determinants of health.

Canada: a land of missed opportunity for addressing the social determinants of health

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organization's Commission on Social Determinants of Health. In this regard, Canada's recent performance suggests a bleak prognosis. Canada's track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canada's capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.

Choosing health, constrained choices

In parallel with the neo-liberal retrenchment of the welfarist state, an increasing emphasis on the responsibility of individuals in managing their own affairs and their well-being has been evident. In the health arena for instance, this was a major theme permeating the UK government's White Paper Choosing Health: Making Healthy Choices Easier (2004), which appealed to an ethos of autonomy and self-actualization through activity and consumption which merited esteem. As a counterpoint to this growing trend of informed responsibilization, constrained choices (constrained agency) provides a useful framework for a judicious balance and sense of proportion between an individual behavioural focus and a focus on societal, systemic, and structural determinants of health and well-being. Constrained choices is also a conceptual bridge between responsibilization and population health which could be further developed within an integrative biosocial perspective one might refer to as the social ecology of health and disease.

Reducing Social and Health Inequalities Requires Building Social and Political Movements

Health inequalities are an outcome of social inequalities and both result from the workings of the economic system, a governmental apparatus that maintains or reinforces these inequalities, and a public discourse that justifies these inequalities. The outcome of these processes is a skewed distribution of exposures among the population to various social (societal) determinants of health. Modifying these societal processes—thereby improving the social determinants of health—requires developing and implementing public policies consistent with reducing these inequalities. Two viewpoints dominate discussions of how this might be brought about: a) professionally-oriented rational or knowledge-based approaches and b) social and political movement-based materialist or political economy-oriented approaches. In political economies dominated by business interests such as those seen in Canada, the US, and UK, adopting a social and political movement-based approach is the most appropriate avenue of action. How this might be accomplished requires critical analysis of the political, economic, and social forces that lead jurisdictions to implement policies that either support or resist equity-oriented public policy innovations.