Geographic information systems as a tool for monitoring health inequalities]

OBJECTIVE: To show how geographic information systems (GISs) can be used as technological tools to support health policy and public health actions. METHODS: We assessed the relationship between infant mortality and a number of socio-economic and geographic determinants. In explaining how GISs are applied, we stressed their ability to integrate data, which makes it possible to perform epidemiologic evaluations in a simpler, faster, automated way that simultaneously analyzes multiple variables with different levels of aggregation. In this study, GISs were applied in analyzing infant mortality data with three levels of aggregation in countries of the Americas from 1995 to 2000. RESULTS: Infant mortality in the Region of the Americas was estimated at an overall average of 24.4 deaths per 1,000 live births. However, the inequalities that were found indicate that the probability of an infant death is almost 20 times greater in the less developed countries of the Region than in more developed ones. Mapping infant mortality throughout the Region of the Americas allowed us to identify the countries that need to focus more attention on health policy and health programs, but not to determine what specific actions are of the highest priority. An analysis of smaller geopolitical units (states and municipalities) revealed important differences within countries. This shows that, as is true of data for the entire Region of the Americas, using national-level average figures for indicators can obscure the differences that exist within countries. When we examined the relationship between female illiteracy and malnutrition as determinants of infant mortality in Brazil and Ecuador, we identified social and epidemiologic strata where risk factors had different distribution patterns and that thus require health interventions that match their individual social and epidemiologic profiles. CONCLUSIONS: With this type of epidemiologic study using GISs at the local level of health services, it is easy to see how a health event and its risk factors behave at a specific period in time. It is also possible to identify patterns in the spatial distribution of risk factors and in these factors' potential impact on health. Using GISs in an appropriate way will make it easier to deliver more effective, equitable public health services.     

Healthy people: a 2020 vision for the social determinants approach

For the past three decades, the Healthy People initiative has represented an ambitious yet achievable health promotion and disease prevention agenda for the nation. The recently released fourth version-Healthy People 2020-builds on the foundations of prior iterations while newly embracing and elevating a comprehensive "social determinants" perspective. By clearly articulating a new overarching goal to "create social and physical environments that promote good health for all" and a new topic area dedicated to defining the social determinants of health approach, it breaks new ground. Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Improving health is too multifaceted to be left to those working in the health sector alone. Using a social determinants approach can reframe the way the public, policy makers, and the private sector think about achieving and sustaining health. This article describes why such a social determinants approach can enhance our collective efforts to improve population health. This is achieved by defining the context for this new perspective, the process by which the Healthy People 2020 goals and objectives were developed, and the challenges and opportunities ahead. Adding this broad, social determinants perspective and vision for shared societal responsibility for change leaves Healthy People 2020 poised to promote a stronger legacy for a healthier nation and reaffirm a unity of purpose for the future.     

US opinions on health determinants and social policy as health policy

To examine what factors the public thinks are important determinants of health and whether social policy is viewed as health policy, we conducted a national telephone survey of 2791 US adults from November 2008 through February 2009. Respondents said that health behaviors and access to health care have very strong effects on health; they were less likely to report a very strong role for other social and economic factors. Respondents who recognized a stronger role for social determinants of health and who saw social policy as health policy were more likely to be older, women, non-White, and liberal, and to have less education, lower income, and fair/poor health. Increasing public knowledge about social determinants of health and mobilizing less advantaged groups may be useful in addressing broad determinants of health.     

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations--and this is especially the case in North America--recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies--the political systems that seem most amenable to securing the social determinants of health--are identified as key to promoting health. Health promoters and population health researchers need to "get political" and recognize the importance of political and social action in support of health.     

Deliberation to enhance awareness of and prioritize socioeconomic interventions for health

Health disparities are, to a large extent, the result of socio-economic factors that cannot be entirely mitigated through the health care system. While an array of social services are thought to be necessary to address the social determinants of health, budget constraints, particularly in difficult economic times, limit the availability of such services. It is therefore necessary to prioritize interventions through some fair process. While it might be appropriate to engage in public deliberation to set priorities, doing so requires that the public accept such a deliberative process and appreciate the social determinants of health. We therefore analyzed the results of a study in which groups deliberated to prioritize socio-economic interventions to examine whether these two requirements can possibly be met and to explore the basis for their priorities. A total of 431 residents of Washington, D.C. with incomes under 200% of the federal poverty threshold participated in 43 groups to engage in a hypothetical exercise to prioritize interventions designed to ameliorate the social determinants of health within the constraints of a limited budget. Findings from pre- and post-exercise questionnaires demonstrate that the priority setting exercise was perceived as a fair deliberative process, and that following the deliberation, participants became more likely to agree that a broad number of determinants contribute to their health. Qualitative analysis of the group discussions indicate that participants prioritized interventions that would provide for basic necessities and improve community conditions, while at the same time addressing more macro-structural factors such as homelessness and unemployment. We conclude that engaging small groups in deliberation about ways to address the social determinants of health can both change participant attitudes and yield informed priorities that might guide public policy aimed at most affordably reducing health disparities.     

The Polarizing Effect of News Media Messages About the Social Determinants of Health

Framing health problems in terms of the social determinants of health aims to shift policy attention to nonmedical strategies to improve population health, yet little is known about how the public responds to these messages. We conducted an experiment to test the effect of a news article describing the social determinants of type 2 diabetes on the public''s support for diabetes prevention strategies. We found that exposure to the social determinants message led to a divergence between Republicans'' and Democrats'' opinions, relative to their opinions after viewing an article with no message about the causes of diabetes. These results signify that increasing public awareness of the social determinants of health may not uniformly increase public support for policy action.Public health advocates have been increasingly promoting the importance of the social determinants of health—the nonmedical, social, economic, political, or environmental factors that influence the distribution of health and illness in the population. Some experts argue that strategically framing health problems in terms of their social determinants could help to turn the public''s and policymakers'' attention to policies that might effectively improve population health and ameliorate health disparities.^1–3 For instance, the World Health Organization Commission on the Social Determinants of Health recently recommended that governments actively incorporate social determinants into their political agendas, making investments in raising public awareness about the impact of social determinants on population health.⁴ In the United States, experts suggest that advocates use the media strategically to educate the public and policymakers about determinants of health other than medical care and health behaviors.^5–7 The implicit assumption of these efforts is that public and political attention to the social determinants of health will lead to increased support for policy interventions to improve public health. However, the claim behind this call to action has received little empirical scrutiny.⁸Substantial theoretical and empirical evidence supports the conventional wisdom that when the public believes that a health problem results from external factors (i.e., from social or environmental determinants) instead of from individuals'' own behaviors or shortcomings, they will be more likely to support social or governmental attempts to address the problem.^9–13 Yet, political science research suggests 2 reasons to challenge this assumption. First, if policymakers and the media emphasize a connection between low socioeconomic status and illness, they will draw attention to a particular social group: those living in poverty. Research indicates that attitudes about social groups are powerful influences on public opinion toward health and social policy. When particular populations are highlighted in the media, people draw upon their attitudes and even prejudices toward these populations when making judgments about policies relevant to the problem at hand.^14,15 Second, empirical research demonstrates that Americans systematically differ in their underlying beliefs about the major causes of poverty, with Republicans less likely to acknowledge the role of social structural factors in influencing socioeconomic status than Democrats and believing more strongly in personal responsibility for social status.^16,17 As a result, political partisans may respond differently to messages about the social determinants of health because of their differing underlying attitudes about those in poverty and the role of personal responsibility.Previous research has demonstrated associations between the public''s perceptions of the causes of illness and their policy opinions. For instance, Oliver and Lee¹¹ and Barry et al.¹⁸ showed that Americans who believed that obesity is caused by an obesity-promoting environment were more likely to support public health policies that target obesity''s environmental determinants (such as regulating school concessions or food advertising). Reutter et al.¹⁹ found that Canadians who believed in structural explanations for health inequalities were more supportive of social policies to address poverty than were those who endorsed behavioral or medical explanations. However, each of these studies, by relying on cross-sectional survey evidence, can only demonstrate correlations, not causation. No previous research to our knowledge has investigated the causal impact of messages about the determinants of health on public attitudes toward specific policies. Yet, given the increasing attention to the health policy implications of social determinants, systematic empirical assessment of this relationship is warranted.We designed an Internet-based experimental study to assess the impact of news media messages about the social determinants of health on public health policy opinions. For this study, we chose type 2 diabetes as an exemplar of the social determinants of health. Type 2 diabetes is the sixth-leading cause of mortality in the United States, and racial, ethnic, and class-related disparities abound in its incidence and prevalence. Although type 2 diabetes is commonly associated with health behaviors (in particular, poor diet, lack of physical activity, and concomitant obesity), these risk factors occur within a context of social and economic influences, including neighborhood environments (e.g., food marketing, price of fruits and vegetables, school concessions) that facilitate unhealthy diets and social stressors that can directly affect insulin resistance.^20,21 In addition, scientists have recently identified and replicated numerous genetic variants that increase susceptibility to type 2 diabetes.²² When selecting a particular cause of diabetes to feature in a news article, that is, when “framing” the causes of diabetes for the public, journalists might choose from among a genetic predisposition frame, a behavioral choices or lifestyles frame, a social determinants frame, or some combination.^23–25 This selection of a causal frame could affect public support for particular strategies to address diabetes (i.e., regulating food marketing or intervening in schools), because public perceptions of the causes of diabetes would affect what level and type of intervention they view as most effective or appropriate.²⁶The goal of our study therefore was to assess the impact of news media framing of the determinants of health—using type 2 diabetes as the example—on public health policy opinions by comparing a social determinants explanation with one that identified genetic predisposition, behavioral choices, or provided no causal explanation. By randomly distributing which hypothetical news article a study participant viewed online, we were able to identify the impact of these causal explanations on participants'' beliefs about the social determinants of diabetes as well as their opinions about policies to prevent diabetes. Given potential differences in predisposing attitudes about the social determinants of health between political partisans, we also assessed whether the impact of the news messages depended on the political orientation of the viewer.     

'Knowledge Infrastructure for Public Health': an advisory report from the Advisory Council on Health Research

Social, scientific and technological developments are forcing health care systems to shift the focus from disease to health and from cure to prevention. The Advisory Council on Health Research (RGO) has published an advisory report about the knowledge infrastructure serving the needs of public health in the Netherlands. The Council's concept of public health also includes aspects such as policy and health management. The Council concludes that more research is needed on the following determinants of health: environmental issues, social factors, unhealthy behaviour and genetic factors. Intervention research must focus on health protection, health promotion and disease prevention. The public health infrastructure can be improved by amalgamating research groups, establishing departments of public health at every academic medical centre, and linking service, education and research.     

What influences the transfer of research into health policy and practice? Observations from England and Australia

OBJECTIVES: To explore the role of evidence in the public health policy-making process, and show how the way in which public health problems are defined and measured influences policy outcomes. METHODS: The policy responses of the Blair Labour Government in the UK and the Howard Coalition Government in Australia to persistent health inequalities over the last decade are examined as a case study. RESULTS: Soon after being elected, the Blair Government commissioned an independent inquiry into health inequalities, signalling the priority it gave to addressing this longstanding challenge. It chose to take a 'whole-of-government' approach, combining actions that addressed both personal risk factors and the social determinants of health. This approach reflects the long-established tradition in England of routinely measuring disparities in health outcomes and correlating them with socio-economic status and underlying social determinants of health. Over the same period, the Howard Government also outlined its 'whole-of-government' approach to addressing the most extreme and persistent health inequalities between indigenous and non-indigenous Australians. In contrast, its approach focused primarily on modifying risk factors and improving service provision. This approach reflects the different historical circumstances in Australia and a different tradition in the collection of health data, focused more on health service access and personal risk factors. CONCLUSIONS: This case study offers some insight into the ways in which the production and presentation of evidence can influence and shape governmental responses to public health problems. The usefulness of available evidence is dependent upon the type of data that is produced routinely by government, as well as more deliberate decisions concerning public health research funding. Researchers can maximize the influence of research evidence on the policy process by engaging in the policy-making process, presenting research in ways that fit with the political context of the day, and, where necessary, using research evidence in public health advocacy in order to influence political priorities more directly.     

Healthy public policy and the World Trade Organization a proposal for an international health presence in future world trade/investment talks

Poverty, other forms of social inequality and human impacts on the environment are increasingly recognized as important, perhaps fundamental, health determinants. These determinants, in turn, are largely conditioned and constrained by economic practices, and by government legislation that regulates such practices or seeks to mitigate inequalities that arise from them. Over the past two decades the ability of national governments to intervene in economic practices has been reduced by two interrelated phenomena: the dominance of a neoliberal economic orthodoxy, which emphasizes free (unregulated) markets and a 'minimal' welfare state, and the growth in regional and global free trade and investment agreements. There is mounting evidence that policies based on neoliberal economic theory, including free trade/investment agreements, may seriously undermine public health by increasing social inequalities, depleting natural resources and increasing environmental pollution. This evidence has sparked a call among many public interest non-governmental organizations (NGOs) and policy 'think tanks' for appending strong 'social clauses' to global trade and investment agreements to ensure that such agreements are socially just and environmentally sustainable. This paper proposes creation of a strong public health lobby, both nationally and internationally, to join with other public interest NGOs in the social clause campaign. It begins by defining and critiquing some of the basic tenets of neoliberal economic orthodoxy which underpin the push towards global free trade and investment agreements. It then describes the current status of these agreements, and provides examples of how such agreements might imperil public health. The paper then discusses the social clause initiative, and concludes by advancing a proposal for a public health lobby presence at those fora where trade and investment agreements are negotiated and monitored.     

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.     

People with disabilities and social determinants of health discourses

Social determinants of health (SDH) are an important public health policy discourse and the concept and scope of SDH is debated within and outside of the public health field. This article concerns itself with the visibility of people with disabilities in existing SDH discourses. It employed a frequency analysis of Google and Google Scholar search hits obtained with the phrase "social determinants of health" in combination with various social groups and looked at the visibility of people with disabilities within key SDH documents, the Millennium Development Goals and some contemporary SDH such as energy, water and climate change security. It found that people with disabilities are much less visible than other social groups despite the major impact SDH have on this population.     

Promoting LGBT health and wellbeing through inclusive policy development

In this paper we argue the importance of including gender and sexually diverse populations in policy development towards a more inclusive form of health promotion. We emphasize the need to address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population health, the social determinants of health (SDOH), and public health goals, in light of the lack of recognition of gender and sexually diverse individuals and communities. By first acknowledging the unique health and social care needs of LGBT people, then employing anti-oppressive, critical and intersectional analyses we offer recommendations for how to make population health perspectives, public health goals, and the design of public health promotion policy more inclusive of gender and sexual diversity. In health promotion research and practice, representation matters. It matters which populations are being targeted for health promotion interventions and for what purposes, and it matters which populations are being overlooked. In Canada, current health promotion policy is informed by population health and social determinants of health (SDOH) perspectives, as demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the challenge of ensuring that diverse populations are equitably and effectively recognized in public health and health promotion policy.     

Communicating population health: Print news media coverage of type 2 diabetes

The public learns much about health and health policy from the news media. The news media can shape the public's opinions about issues by emphasizing certain features in their coverage, such as the causes of a problem, who is responsible for addressing it, and what groups are affected. This study examines media framing of the problem of type 2 diabetes, focusing on the extent to which the news media discuss diabetes using features that characterize a population health orientation (mentioning social determinants, upstream interventions, or disparities). We collected data from 698 print news articles appearing in 19 U.S. newspapers between 2005 and 2006. Results demonstrate that the predominant explanation for type 2 diabetes was behavioral factors and obesity. The predominant strategy to address diabetes was individualized behavior changes and medical care. A minority of articles described the social determinants of diabetes, upstream policy solutions, and disparities in diabetes; such articles appeared in a select subset of news outlets. These findings suggest the potential for great variability in public awareness of disparities in diabetes or its social determinants, with implications for the public's likelihood of supporting policies that may improve population health.     

Building an inter-disciplinary science of health inequalities: the example of lifecourse research

Across the post-industrial world, new public health strategies are being developed with the goal of reducing the socio-economic gradient in health. These new strategies are distinguished by a commitment to tackling the macro determinants of health inequalities through policies informed by scientific evidence. The engagement with macro determinants and with scientific evidence presents a major challenge to the health inequality research community. This is not only because of the complexity of the links between distal causes, proximal risk factors and health outcomes. It is also and more importantly because of the narrow disciplinary base of health inequality research. Grounded in social epidemiology, health inequality research has illuminated the pathways which run from individual socio-economic position to health-but has left in shadow the factors which influence socio-economic position. Broadening the evidence base to include these structural processes requires a new science of health inequalities, resourced both by epidemiological research and by research on social inequality and social exclusion. The paper demonstrates how such an inter-disciplinary science can be constructed. Taking lifecourse research as its example and the UK as its case study, it nests epidemiological research within social policy research: setting evidence on the health consequences of cumulative exposures within research on lifecourse dynamics, and locating both within analyses of how state policies can amplify or moderate inequalities in socio-economic position.     

Biological basis of determinants of health

Clinical medicine and health policy planning find common cause as they seek to define the determinants of health. There is substantial recent interest in the social ecology in which health is embedded. However, biology is where these contributing environmental factors are translated. I provide a new conceptual framework for the biological determinants of health. The old public health rubric of host, agent, and environment as the features that define the root elements of health is an impoverished scheme, because it does not represent our new appreciation of genetic and aging contributions to phenotypic health. I propose genes, external agency, internal agency, and aging as more operationally helpful determinants that effectively describe the biological experience of the organism. This scheme has the advantage of differentiating those agencies that are practically approachable, and therefore deserving of increased attention and investment, and those that are currently intractable.     

Using theory to understand the multiple determinants of low participation in worksite health promotion programs.

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.     

Defining and measuring gender: A social determinant of health whose time has come

This paper contributes to a nascent scholarly discussion of sex and gender as determinants of health. Health is a composite of biological makeup and socioeconomic circumstances. Differences in health and illness patterns of men and women are attributable both to sex, or biology, and to gender, that is, social factors such as powerlessness, access to resources, and constrained roles. Using examples such as the greater life expectancy of women in most of the world, despite their relative social disadvantage, and the disproportionate risk of myocardial infarction amongst men, but death from MI amongst women, the independent and combined associations of sex and gender on health are explored. A model for incorporating gender into epidemiologic analyses is proposed.     

Crossing borders: a critical review of the role of the European Court of Justice in EU health policy

Over the last two decades, the European Union (EU) has steadily increased its involvement in the health policies of its member states, with considerable support from the European Court of Justice (ECJ). However, much of the literature examining the Court's role has focused upon the intersection between internal market law and the health services sector; the majority of studies have failed to examine the potential role for the Court in public health policy. Observers such as Greer have seen the development of healthcare as a clear case of neofunctional spillover, a view supported but qualified by Wasserfallen and others, who present a more detailed account of the mechanics of the process. Alternative analyses have focused upon the new modes of governance, soft law and other factors - this article reviews the current state of research in the field and the extent to which it should concern health policy actors and non-specialists in EU policy alike. It concludes that the Court has played and continues to play a crucial role in the development of EU public health policy, as well as in health services and broader social policy, where its influence has already been well documented.