The Case for the World Health Organization’s Commission on the Social Determinants of Health to Address Sexual Orientation

The World Health Organization''s (WHO''s) social determinants of health discussion underscores the need for health equity and social justice. Yet sexual orientation was not addressed within the WHO Commission on the Social Determinants of Health final report Closing the Gap in a Generation.This omission of sexual orientation as a social determinant of health stands in stark contrast with a body of evidence that demonstrates that sexual minorities are disproportionately affected by health problems associated with stigma and discrimination, such as mental health disorders.I propose strategies to integrate sexual orientation into the WHO’s social determinants of health dialogue. Recognizing sexual orientation as a social determinant of health is an important first step toward health equity for sexual minorities.Health equity and social justice are central to the World Health Organization’s (WHO’s) discussion of the social determinants of health.1 The WHO’s Commission on the Social Determinants of Health (CSDH) 2008 final report, Closing the Gap in a Generation, defined social determinants of health as living conditions shaped by sociopolitical factors that contribute to the health of individuals and populations.1 The social determinants of health were operationalized in nine themes: early childhood development, globalization, health systems, employment conditions, priority public health conditions, measurement and evidence, women and gender equality, urbanization, and social exclusion.The CSDH social determinants of health conceptual framework posits that factors associated with the distribution of health and well-being include social position, education, occupation, income, gender, and ethnicity/race.1 Sexual orientation was not included within CSDH’s social determinants of health conceptual framework nor mentioned anywhere in this report.1 Yet sexual minorities experience significant and pervasive health disparities. (I use the terms “sexual minority” and “lesbian, gay, bisexual” [LGB] interchangeably to convey nonheterosexual sexualities and identities claimed by persons across diverse cultures and contexts.) For example, systematic reviews and population-based studies report increased risks for depression,2–7 suicidal ideation,2,3,7–9 anxiety,2,3,5–7 and substance dependence2,4,6 among sexual minorities compared with heterosexuals.Open in a separate windowA woman prays next to the coffin of Erick Alex Martinez, a journalist and gay rights campaigner, who was murdered in Honduras along with at least 20 other media workers over the last 3 years. Martinez''s body was found by the roadside in the village of Guasculile, north of the capital, Tegucigalpa. He worked for an association defending lesbian, gay, bisexual, and transgender (LGBT) rights. Martinez had also been chosen last year as a candidate for a coalition of parties that emerged after the ousting of President Manuel Zelaya in 2009. Photograph by Orlando Sierra. Printed with permission of Getty Images.Omission of sexual orientation as a social determinant of health in Closing the Gap in a Generation stands in stark contrast with a large body of evidence that demonstrates that sexual minorities are disproportionately affected by health problems associated with stigma and discrimination.2,5,10 Homosexuality is criminalized in 76 countries and punishable by death in five,11 underscoring the impact of powerful sociopolitical factors on the lives of sexual minorities. Sexual minorities are a demographic that account for a significant proportion of the global disease burden, which is strongly impacted by sociopolitical factors; therefore, they should be included in health equity discussions. My objective is to demonstrate the importance of explicitly recognizing stigma and discrimination targeting sexual minorities as a social determinant of health to promote health equity.     

The Case for the World Health Organization’s Commission on Social Determinants of Health to Address Gender Identity

We analyzed the case of the World Health Organization’s Commission on Social Determinants of Health, which did not address gender identity in their final report.We argue that gender identity is increasingly being recognized as an important social determinant of health (SDH) that results in health inequities. We identify right to health mechanisms, such as established human rights instruments, as suitable policy tools for addressing gender identity as an SDH to improve health equity.We urge the World Health Organization to add gender identity as an SDH in its conceptual framework for action on the SDHs and to develop and implement specific recommendations for addressing gender identity as an SDH.Gender identity is frequently overlooked when social determinants of health (SDHs) are being discussed. We analyzed the case of the World Health Organization’s (WHO’s) Commission on Social Determinants of Health as an initial driver of the SDH movement, which did not address gender identity in their final report published in 2008.1 Subsequent international initiatives focused on the SDHs, such as the Rio Political Declaration on the Social Determinants of Health2 adopted in 2011 and the WHO European Review of the Social Determinants of Health and the Health Divide3 published in 2012, have also omitted gender identity. We argue that gender identity is increasingly being recognized as an important SDH that results in health inequities and should be addressed to improve health equity, including through the application of human rights instruments.     

Social Expenditure on Health Service and Its Macro Estimation

By social expenditure on health service(SEHS)we refer to the sum total of money paid by thewhole society during a certain period of year for the sake of preventing and treating diseases andof protecting and improving the people's health.It reflects objectively the total level of SEHSduring a certain period;the levels of health service expenditures on the parts of the whole society,enterprises,and individuals;the ratio between SEHS and total social expenditure;and the ratiosof SEHS to gross national product and to national income.The article discussed and analysed     

'How do you pay your rent?' Social policies and the President's Mental Health Commission

Mental health policy involves broad social policies related to housing, education, work disability and rehabilitation, welfare, and criminal justice. The modern era of community care has moved patients, clinicians, and policymakers from closed institutions into the mainstream of society and its health and human service systems. The importance of knowing about the broad array of human services and their policies is reflected in the deliberations and policy recommendations of the President's New Freedom Commission on Mental Health. It is hoped that these recommendations will provide a roadmap for further change to enable people affected by severe mental illness "to live, learn, work, and participate fully in their communities."     

Public Health,Academic Medicine,and the Alcohol Industry’s Corporate Social Responsibility Activities

We explored the emerging relationships among the alcohol industry, academic medicine, and the public health community in the context of public health theory dealing with corporate social responsibility. We reviewed sponsorship of scientific research, efforts to influence public perceptions of research, dissemination of scientific information, and industry-funded policy initiatives.To the extent that the scientific evidence supports the reduction of alcohol consumption through regulatory and legal measures, the academic community has come into increasing conflict with the views of the alcohol industry.We concluded that the alcohol industry has intensified its scientific and policy-related activities under the general framework of corporate social responsibility initiatives, most of which can be described as instrumental to the industry’s economic interests.WE EXPLORED THE EMERGING relationships between the alcohol industry, academic medicine, and the public health community. Current trends suggest increasing involvement of the alcohol beverage industry in areas that traditionally have been the main foci of public health and academic medicine, such as scientific research, alcohol education, prevention programs, and alcohol control policies.1,2 Many of these activities can be interpreted in terms of corporate social responsibility (CSR) initiatives that many large corporations practice.3 We define CSR as business practices that help companies manage their economic, social, and environmental impacts as well as their relationships in key areas of influence, such as the marketplace, the supply chain, the community, and the public policy arena.To provide a context for an evaluation of the alcohol industry’s CSR activities, we reviewed the most prominent health issues that threaten the viability of the alcohol industry as a whole and that represent points of contention with public health and academic medicine. We have described the industry’s CSR activities and the risks involved for the academic community. We have provided an evaluation of the theoretical, scientific, and public health challenges that have emerged from industry involvement in alcohol-related health issues.     

Ethnic Health Care Advisors: A Good Strategy to Improve the Access to Health Care and Social Welfare Services for Ethnic Minorities?

Empirical studies indicate that ethnic minorities have limited access to health care and welfare services compared with the host population. To improve this access, ethnic health care (HC) advisors were introduced in four districts in Amsterdam, the Netherlands. HC advisors work for all health care and welfare services and their main task is to provide information on health care and welfare to individuals and groups and refer individuals to services. Action research was carried out over a period of 2 years to find out whether and how this function can contribute to improve access to services for ethnic minorities. Information was gathered by semi-structured interviews, analysing registration forms and reports, and attending meetings. The function’s implementation and characteristics differed per district. The ethnicity of the health care advisors corresponded to the main ethnic groups in the district: Moroccan and Turkish (three districts) and sub-Sahara African and Surinamese (one district). HC advisors reached many ethnic inhabitants (n = 2,224) through individual contacts. Half of them were referred to health care and welfare services. In total, 576 group classes were given. These were mostly attended by Moroccan and Turkish females. Outreach activities and office hours at popular locations appeared to be important characteristics for actually reaching ethnic minorities. Furthermore, direct contact with a well-organized back office seems to be important. HC advisors were able to reach many ethnic minorities, provide information about the health care and welfare system, and refer them to services. Besides adapting the function to the local situation, some general aspects for success can be indicated: the ethnic background of the HC advisor should correspond to the main ethnic minority groups in the district, HC advisors need to conduct outreach work, there must be a well-organized back office to refer clients to, and there needs to be enough commitment among professionals of local health and welfare services.     

Health by association? Social capital, social theory, and the political economy of public health

Three perspectives on the efficacy of social capital have been explored in the public health literature. A "social support" perspective argues that informal networks are central to objective and subjective welfare; an "inequality" thesis posits that widening economic disparities have eroded citizens' sense of social justice and inclusion, which in turn has led to heightened anxiety and compromised rising life expectancies; a "political economy" approach sees the primary determinant of poor health outcomes as the socially and politically mediated exclusion from material resources. A more comprehensive but grounded theory of social capital is presented that develops a distinction between bonding, bridging, and linking social capital. It is argued that this framework helps to reconcile these three perspectives, incorporating a broader reading of history, politics, and the empirical evidence regarding the mechanisms connecting types of network structure and state-society relations to public health outcomes.     

Can Social Care Needs and Well-Being Be Explained by the EQ-5D? Analysis of the Health Survey for England

Background

The recent shift to an integrated approach to health and social care aims to provide cohesive support to those who are in need of care, but raises a challenge for resource allocation decision making, in particular for comparison of diverse benefits from different types of care across the two sectors.

The Social Meanings of Traditional Chinese Medicine: Elderly Chinese Immigrants’ Health Practice in the United States

We situate elderly Chinese immigrants' utilization of traditional Chinese medicine (TCM) in social contexts (e.g., family and social networks), exploring how TCM is used as a tool, a resource, and a product of meaning-construction in their everyday life. We conducted in in-depth interviews with 20 elderly Chinese immigrants in the United State, exploring the complexity of their understanding and practice of TCM. We used grounded theory to identify the set of meanings that are particular to elderly Chinese immigrants' use of TCM as a part of their health practice. For our participants, TCM is not just a resource for illness management. Instead, incorporating TCM in their health practice allows them to: (a) perform and reaffirm their cultural identity as Chinese, (b) maintain their moral status and fulfill their social roles, and (c) pass down health knowledge and cultural heritage. Clinical implications were discussed.     

Assessment of University Students’ Suboptimal Health and Social Media Use: Implications for Health Regulatory Authorities

Journal of Community Health - This study aimed to assess the patterns of social media usage amongst university students at Ajman University (AU) and to explore health issues in relation to social...     

Social Capital,Participation and the Perpetuation of Health Inequalities: Obstacles to African‐Caribbean Participation in ‘Partnerships’ to Improve Mental Health

Objectives. There has recently been much emphasis on the role of ‘partnerships’ between local community ‘stakeholders’ in strategies to redress health inequalities. This paper examines obstacles to participation in such partnerships by African‐Caribbean lay people in local initiatives to improve mental health in a town in southern England. We present a ‘social psychology of participation’ which we use to interpret our data. Our work seeks to illustrate some of the micro‐social mechanisms through which social inequalities are perpetuated, using Bourdieu's conceptualisation of the role played by various forms of capital (economic, social, cultural and symbolic) in perpetuating social inequalities.

Design. Our empirical research consists of a qualitative case study of attitudes to participation in mental‐health‐related partnerships in a deprived community. In‐depth interviews and focus groups were conducted with 30 local community ‘stakeholders’, drawn from the statutory, voluntary, user and lay sectors.

Results. While interviewees expressed enthusiasm about the principles of participation, severe obstacles to its effective implementation were evident. These included severe distrust between statutory and community sectors, and reported disillusionment and disempowerment within the African‐Caribbean community, as well as low levels of community capacity. Moreover, divergent understandings of the meaning of ‘partnership’ suggested that it would be difficult to satisfy both community and statutory sectors at once.

Conclusions. We suggest that disadvantaged and socially excluded communities are often deprived of the social resources which would provide a solid basis for their participation in partnerships with state health services. In the absence of efforts to remove such obstacles, and to generate the necessary resources for participation, partnerships may be ‘set up to fail’, leaving social inequalities to prevail.     

Mother-Perceived Social Capital and Children’s Oral Health and Use of Dental Care in the United States

Objectives. We examined the association between mother-perceived neighborhood social capital and oral health status and dental care use in US children.Methods. We analyzed data for 67 388 children whose mothers participated in the 2007 National Survey of Children’s Health. We measured mothers’ perceived social capital with a 4-item social capital index (SCI) that captures reciprocal help, support, and trust in the neighborhood. Dependent variables were mother-perceived ratings of their child’s oral health, unmet dental care needs, and lack of a previous-year preventive dental visit. We performed bivariate and multivariable logistic regression analyses for each outcome.Results. After we controlled for potential confounders, children of mothers with high (SCI = 5–7) and lower levels (SCI ≥ 8) of social capital were 15% (P = .05) and about 40% (P ≤ .02), respectively, more likely to forgo preventive dental visits than were children of mothers with the highest social capital (SCI = 4). Mothers with the lowest SCI were 79% more likely to report unmet dental care needs for their children than were mothers with highest SCI (P = .01).Conclusions. A better understanding of social capital’s effects on children’s oral health risks may help address oral health disparities.It is well established that children living in families with low income and low educational attainment have poorer oral health and access to dental care than children with more affluent and educated families.1,2 Previous research has rigorously described oral health disparities by sociodemographic characteristics of individuals over the years, but only more recently have investigations begun to study the influence of larger contextual, environmental, and societal factors on the population’s oral health.3–6As part of this broader interest in the social determinants of health, the social connections that people have within their communities are receiving growing interest in public health research. This interest is rooted, in part, in the potential for people’s social connections to reduce health inequities through the mobilization of resources in society to better facilitate access to horizontally and vertically available social capital. Furthermore, social capital in the neighborhood may be particularly important for children’s well-being because the neighborhood is usually a central context for children’s psychosocial development. Children learn many of their social skills and values from within their neighborhood social networks.7 Especially in the absence of different kinds of support for children within the family,8 adult intervention on behalf of children in the neighborhood could serve as an important buffer against stressors and social risk factors embedded in the context of children’s lives.Although there is no consensus definition or a standardized approach to measuring social capital, it usually is thought of as consisting of some aspect of social structure and actions of individuals embedded in that structure.7 In social cohesion theory, social capital is conceptualized as the collective resources, such as trust, norms, and reciprocity, available to members of social groups, usually defined by geographic locales.9,10 This “social cohesion” school of social capital has been criticized for overlooking some aspects of social capital such as differences in residents’ abilities to access social capital and its potential negative effects on health.9,11 Nevertheless, greater social capital, measured by various features of social organizations in the community, has been linked to lower mortality and morbidity as well as self-reported better health outcomes.12 The hypothesized mechanisms are that social capital can influence health through (1) the diffusion of knowledge about health promotion, (2) maintenance of healthy behavioral norms or prevention of deviant health-related behaviors through informal social control, (3) promotion of access to local services and amenities, and (4) psychosocial processes that provide effective support, build self-esteem, and foster mutual respect.13It has been reported in the dental literature that a greater number of churches in neighborhood clusters was associated with the reduced severity of dental caries among low-income African American preschool children residing in Detroit, Michigan.3 Bramlett et al. previously examined various child-, family-, and neighborhood-level factors available in the 2003 National Survey of Children’s Health (NSCH) along with state-level factors from a variety of surveillance and census databases to test a multilevel conceptual model of determinants of young children’s oral health.5 Factors related to neighborhood cohesiveness and physical safety were correlated with parent-rated oral health status in children aged 1 through 5 years.5 Lower neighborhood social capital and community empowerment opportunities were also linked to higher rates of dental injuries14 and more dental caries among Brazilian adolescents.15Hypothesized sociobehavioral mechanisms linking social capital to health, empirical evidence on the association of social capital and general health, and initial evidence on the association of social capital–related variables and oral health strongly support further study of its potential impact on children’s oral health. It is evident from the literature that maternal oral health status, knowledge, and self-efficacy have a significant influence on children’s oral health behaviors and outcomes.16–19 In addition, gender may affect one’s perception of neighborhood social capital, patterns, and levels of social engagement and community participation.20,21 Little is known, however, about how social capital is perceived by female caregivers of children and how it might influence their behaviors and their children’s oral health. The purposes of this study were, therefore, to (1) describe the distribution of perceived social capital, using population-based data of self-reported neighborhood social cohesion among US mothers of children younger than 18 years, and (2) determine the association between neighborhood social capital and children’s oral health status and use of dental care.     

Women's Social Position and Health-Seeking Behaviors: Is the Health Care System Accessible and Responsive in Pakistan?

To make the health care system more accessible and responsive to women particularly in developing countries, it is imperative to study the health-seeking behaviors and factors determining utilization of health care services. This study was carried out in close collaboration with Aga Khan Health Services, Pakistan (AKHSP) and the Health Department of Northern Areas of Pakistan. Key findings indicate that more than one-third of women did not know the cause of their reported illness. There is a median delay of 3 days before a consultation. Local women utilize AKHSP services far more than other health services due to the quality of services offered and the availability of female health staff. The perception of receiving the required treatment is lowest for government health services. Consulting faith healers is a common practice. Health education and health promotion campaigns are needed to change existing health-seeking behaviors among women. Social arrangements should be thoughtfully considered to make the health system more responsive. More female staff needs to be deployed in government health facilities. A public–private partnership seems to provide a means to strengthen the health care system and consequently to promote women's health.     

Promoting the Psychosocial Health of the Elderly—

Abstract

With the ageing of the global population, the wellbeing of older people in different parts of the world merits special attention. However, recent findings on certain aspects of the psychosocial health of the elderly are far from reassuring. The first problem is the inconsistency in psychosocial indicators, which give simultaneous high life satisfaction scores and high suicide rates. The second problem is the significant weakening of the social support network of the elderly. This article analyses the service and policy implications of these two problems. Suggestions are then made on the role of social workers in promoting the psychosocial health of the elderly at different levels of intervention, which include the individual level, the family and social network level, the community level and the international level.     

Towards Health Equity: Deaf Adults’ Engagement in Social e-Health Activities and e-Communication with Health Care Providers

Deaf people face significant barriers with accessing health information, health care services, and communication with their health care provider and as a result, show poorer health outcomes compared to the general population. Studies on the general population found that those who use social network sites (SNS) for health-related activities were more likely to communicate with their health care provider via the Internet or email. For deaf individuals who use American Sign Language (ASL), using eHealth platforms to communicate with health care providers has the potential to navigate around communication barriers and create greater opportunity to discuss screening and treatment plans. Using national data from the HINTS-ASL survey, we explored whether engagement in social eHealth activities on SNS is linked to electronic communication with health care providers after controlling for deaf patient characteristics. Our sample for this study consisted of 515 deaf participants who reported using (social media/SNS) to read and share health information. Controlling for sociodemographic variables, participants who engaged in social eHealth activity were threefold more likely to communicate with their healthcare provider electronically. Using eHealth platforms for social health engagement demonstrates potential to reduce health inequality among deaf people.     

Industrial Health—Meeting the Challenge

The modern industrial system had its origin in England just over 200 years ago. This period historically is referred to as the Industrial Revolution. It was marked by mechanical inventions in textile machinery, by advances in the manufacture of iron, and by the introduction of steam power. These, in turn, were the foundations of the factory system.

In 1784 at a cotton mill at Radcliffe, near Manchester, an epidemic of malignant fever affected the operatives and spread to the surrounding population. The situation became serious and the local justices invited Dr. Thomas Percival, a leading local physician, to investigate the nature and circumstances of the outbreak. With his colleagues and leading citizens he formed the Manchester Board of Health. The Board, through authoritative reports, made recommendations for the control of such epidemics by the establishment of isolation hospitals. They also urged the need for the improvement of environmental conditions in mills and factories and for the diminution of working hours, especially for children and women. In pursuance of these objects the Government in 1802 passed the Health and Morals of Apprentices Act. This was the first Factory Act. Since then factory legislation has been greatly extended and is the basis of statutory supervision of factories and factory workers under the inspector of factories. The development of this supervision is traced with special reference to the work of the certifying surgeons, now the appointed factory doctors, and the medical inspectors. Concurrently, public health education and workmen's compensation were advanced through legislation. Since 1935 voluntary medical services have been developed in industry. These services have not been restricted to the observance of the minimum standards prescribed by statute and so have been able to pioneer advances directed to the promotion of safety, health, and welfare in factories and other places of employment.

Radcliffe, Percival, and steam power are recognized as the growing points of the challenge to health by the Industrial Revolution. The means whereby the challenge was met are discussed.

Towards the end of the nineteenth century scientists increasingly concentrated their studies on the elements. This culminated in the isolation of the atom. During the last 10 years atomic power has become a reality and the foundation of the second Industrial Revolution. While the potential hazards of ionizing radiations had long been known and proved at Hiroshima, the inherent dangers for the general population only became impressed on the public mind by a breakdown at the Windscale No. 1 plutonium pile on October 10, 1957. Radio-active iodine escaped, contaminating the atmosphere as far afield as western Europe. A committee under the chairmanship of Sir Alexander Fleck was appointed to investigate the cause of the accident and its consequences and to make recommendations. The report, which laid special emphasis on safety and health, was published early in 1958. So by analogy, Windscale, Fleck, and atomic power are identified as the growing points of the challenge of the Second Industrial Revolution. How this challenge is to be met by doctors is discussed. It is submitted that the urgent need is to formulate now a basic philosophy for future development of industrial medicine. Continuation of the old order will not suffice: ideas must again become revolutionary. The responsibility for leadership rests on the Industrial Health Advisory Committee established in 1955 under the chairmanship of the Minister of Labour and National Service.