Embodied health movements: new approaches to social movements in health

Social movements organised around health-related issues have been studied for almost as long as they have existed, yet social movement theory has not yet been applied to these movements. Health social movements (HSMs) are centrally organised around health, and address: (a) access to or provision of health care services; (b) health inequality and inequity based on race, ethnicity, gender, class and/or sexuality; and/or (c) disease, illness experience, disability and contested illness. HSMs can be subdivided into three categories: health access movements seek equitable access to health care and improved provision of health care services; constituency-based health movements address health inequality and health inequity based on race, ethnicity, gender, class and/or sexuality differences; and embodied health movements (EHMs) address disease, disability or illness experience by challenging science on etiology, diagnosis, treatment and prevention. These groups address disproportionate outcomes and oversight by the scientific community and/or weak science. This article focuses on embodied health movements, primarily in the US. These are unique in three ways: 1) they introduce the biological body to social movements, especially with regard to the embodied experience of people with the disease; 2) they typically include challenges to existing medical/scientific knowledge and practice; and 3) they often involve activists collaborating with scientists and health professionals in pursuing treatment, prevention, research and expanded funding. This article employs various elements of social movement theory to offer an approach to understanding embodied health movements, and provides a capsule example of one such movement, the environmental breast cancer movement.     

Decomposing socioeconomic inequality in infant mortality in Iran

BACKGROUND: Although measuring socioeconomic inequality in population health indicators like infant mortality is important, more interesting for policy purposes is to try to explain infant mortality inequality. The objective of this paper is to quantify for the first time the determinants' contributions of socioeconomic inequality in infant mortality in Iran. METHODS: A nationally representative sample of 108 875 live births from October 1990 to September 1999 was selected. The data were taken from the Iranian Demographic and Health Survey (DHS) conducted in 2000. Households' socioeconomic status was measured using principal component analysis. The concentration index of infant mortality was used as our measure of socioeconomic inequality and decomposed into its determining factors. RESULTS: The largest contributions to inequality in infant mortality were owing to household economic status (36.2%) and mother's education (20.9%). Residency in rural/urban areas (13.9%), birth interval (13.0%), and hygienic status of toilet (11.9%) also proved important contributors to the measured inequality. CONCLUSIONS: The findings indicate that socioeconomic inequality in infant mortality in Iran is determined not only by health system functions but also by factors beyond the scope of health authorities and care delivery system. This implies that in addition to reducing inequalities in wealth and education, investments in water and sanitation infrastructure and programmes (especially in rural areas) are necessary to realize improvements of inequality in infant mortality across society. These findings can be instrumental for the recent 5 year Economic, Social and Cultural Development Plan of Iran, which identified the reduction of inequalities in social determinants of health.     

Indicadores para monitorizar la evolución de la crisis económica y sus efectos en la salud y en las desigualdades en salud. Informe SESPAS 2014

The economic crisis has adverse effects on determinants of health and health inequalities. The aim of this article was to present a set of indicators of health and its determinants to monitor the effects of the crisis in Spain. On the basis of the conceptual framework proposed by the Commission for the Reduction of Social Health Inequalities in Spain, we searched for indicators of social, economic, and political (structural and intermediate) determinants of health, as well as for health indicators, bearing in mind the axes of social inequality (gender, age, socioeconomic status, and country of origin). The indicators were mainly obtained from official data sources published on the internet. The selected indicators are periodically updated and are comparable over time and among territories (among autonomous communities and in some cases among European Union countries), and are available for age groups, gender, socio-economic status, and country of origin. However, many of these indicators are not sufficiently reactive to rapid change, which occurs in the economic crisis, and consequently require monitoring over time. Another limitation is the lack of availability of indicators for the various axes of social inequality. In conclusion, the proposed indicators allow for progress in monitoring the effects of the economic crisis on health and health inequalities in Spain.     

Social Determinants,Suboptimal Health Behavior,and Morbidity in Urban Slum Population: An Indian Perspective

Improving the health of urban residents, particularly those living in slum areas, requires an integrated approach. Appropriate interventions must be based on a well-grounded understanding of health determinants. Social factors are as important as physical factors in determining health status and suggest alternative interventions. Employment, stress, social exclusion, social support, substance use, nutrition, transport, and conditions during childhood are among the most important social determinants of health status identified by the International Center for Health and Society. This paper uses social determinants of health approach to understand morbidity outcomes for people residing in the slums of Surat City, India. To quantify suboptimal health behavior and identify the determinants of health status for this population survey data on household characteristics, health-seeking behavior, socioeconomic status, food and personal habits, social life, and physical activity has been used. After controlling for socioeconomic and demographic factors, logistic regression analysis reveals that social exclusion, stress, and lack of social support are significantly associated with morbidity. Thus, understanding of social determinants of health by policy makers is important as the health sector has a crucial role in addressing disparities in social determinants.     

Social Determinants and Health Service Use Among Racial and Ethnic Minorities: Findings From a Community Sample

Multiple models conceptualizing the relationship between social determinants and health exist, but little research has examined the relationship between social determinants and health service use. Using previously collected survey data from racial and linguistic minorities from high-crime communities in a Midwestern urban area, this study uses the Commission on Social Determinants of Health framework to test the structural and intermediary determinants of health service use. The results indicate that perceived discrimination and neighborhood cohesion increase the likelihood of a person using health services. Implications for social work practice, advocacy, and research to address intermediary social determinants are discussed.     

Fair society, healthy lives

The final report of the World Health Organization Commission on the Social Determinants of Health (CSDH), published in 2008, affirmed that social injustice was killing on a grand scale, with a toxic combination of 'poor social policies and programmes, unfair economic arrangements, and bad politics' being responsible for producing and reinforcing health inequalities. It provided a comprehensive evidence-based discussion of pervasive inequalities of health in many countries, demonstrating the presence of a social gradient in health outcomes associated with the unfair distribution of the social determinants of health. The social determinants of health include the conditions in which people are born, grow, live, work and age, and the fundamental drivers of these conditions: the distribution of power; money; and resources. Following publication of the CSDH report and recommendations for action, the UK Government commissioned a Strategic Review of Health Inequalities in England. This article provides an overview and reflection on the findings from the CSDH and the Strategic Review of Health Inequalities in England, reviewing the case for putting fairness at the heart of all policy making. In the process, it highlights the need for action on the social determinants of health in order to address health inequalities and the social gradient in health outcomes.     

Social determinants and health service use among racial and ethnic minorities: findings from a community sample

Multiple models conceptualizing the relationship between social determinants and health exist, but little research has examined the relationship between social determinants and health service use. Using previously collected survey data from racial and linguistic minorities from high-crime communities in a Midwestern urban area, this study uses the Commission on Social Determinants of Health framework to test the structural and intermediary determinants of health service use. The results indicate that perceived discrimination and neighborhood cohesion increase the likelihood of a person using health services. Implications for social work practice, advocacy, and research to address intermediary social determinants are discussed.     

Income-related health inequalities in France in 2004: Decomposition and explanations

BackgroundThis analysis supplements existing work on social health inequalities at two levels: the measurement of health and the measurement of inequalities. Firstly, individual health status was measured using a subjective health indicator corrected within a promising cardinalisation method which had not yet been carried out on French data. Secondly, this study used an innovative methodology to measure income-related health inequalities, to understand the relationships between income, income inequality, various social determinants, and health.MethodsThe analysis was based on a sample of working-age adults from the 2004 Health and Health Insurance Survey. The methodology used in the study measures the total income-related health inequality using the concentration index. This index is based on a linear model explaining health according to several individual characteristics, such as age, sex, and various socioeconomic characteristics. The method thus takes into account both the causal relationships between the various explicative factors introduced in the model and their relationship with health. Furthermore, it concretely measures the contribution of the social determinants to income-related health inequalities.ResultsThe results show an income-related health inequality favouring individuals with a higher income. Moreover, income level, supplementary private health insurance, education level, and social class account for the main contributions to inequality. Therefore, the decomposition method highlights population groups that policies should target.ConclusionThe study suggests that reducing income inequality is not sufficient to lower income-related health inequalities in France in 2004 and needs to be supplemented with the reduction of the relationship between income and health and the reduction of income inequality over socioeconomic status.     

Les inégalités de santé selon le revenu en France en 2004 : décomposition et explications

BackgroundThis analysis supplements existing work on social health inequalities at two levels: the measurement of health and the measurement of inequalities. Firstly, individual health status was measured using a subjective health indicator corrected within a promising cardinalisation method which had not yet been carried out on French data. Secondly, this study used an innovative methodology to measure income-related health inequalities, to understand the relationships between income, income inequality, various social determinants, and health.MethodsThe analysis was based on a sample of working-age adults from the 2004 Health and Health Insurance Survey. The methodology used in the study measures the total income-related health inequality using the concentration index. This index is based on a linear model explaining health according to several individual characteristics, such as age, sex, and various socioeconomic characteristics. The method thus takes into account both the causal relationships between the various explicative factors introduced in the model and their relationship with health. Furthermore, it concretely measures the contribution of the social determinants to income-related health inequalities.ResultsThe results show an income-related health inequality favouring individuals with a higher income. Moreover, income level, supplementary private health insurance, education level, and social class account for the main contributions to inequality. Therefore, the decomposition method highlights population groups that policies should target.ConclusionThe study suggests that reducing income inequality is not sufficient to lower income-related health inequalities in France in 2004 and needs to be supplemented with the reduction of the relationship between income and health and the reduction of income inequality over socioeconomic status.     

Ethics and prevention: environmental and individual disparities

The complex interactions which exist between environmental variabilities, genetic susceptibility of population subgroups, and high individual variability for age, sex, gender, ethnicity and general status of health, acquire an ever-increasing bioethical significance. Different risk conditions caused by toxic environmental agents and environmental inequities and inequalities are increasingly evident. "Social determinants" of health increase the probability of health effects and an effective intervention of prevision and prevention for environmental pathologies is needed. The debate on environmental inequalities caused by cultural, social and economic factors and the uncertainty about possible prevention emphasize the limits of the "bio-medical model". Ethics with its further anthropological and philosophical considerations may strongly help to understand the relationship between environmental pollution and health.     

Environmental equity, air quality, socioeconomic status, and respiratory health: a linkage analysis of routine data from the Health Survey for England

STUDY OBJECTIVE: To assess relations between socioeconomic status and local air quality, and combined effects on respiratory health, in the context of environmental and health inequality. DESIGN: Data on people taking part in the Health Survey for England were attributed with a small area index of air pollution using annual mean concentrations of nitrogen dioxide, sulphur dioxide, benzene, and particulates (PM10). Regression models were used to measure associations between social class, air quality, forced expiratory volume in one second (FEV1), and self reported asthma. PARTICIPANTS: Participants aged 16-79 in the Health Survey for England 1995, 1996, and 1997. MAIN RESULTS: Urban lower social class households were more likely to be located in areas of poor air quality, but the association in rural areas was, if anything reversed. Low social class and poor air quality were independently associated with decreased lung function (FEV1), but not asthma prevalence, after adjustment for a number of potential confounders. Social class effects were not attenuated by adjustment for air quality. In men, a differential effect of air pollution on FEV1 was found, with its effect in social classes III to V about double that in social classes I and II (p value for interaction = 0.04). This effect modification was not seen for women. CONCLUSIONS: Further evidence of environmental inequity in the UK is provided. The association between FEV1 and local air quality is of similar magnitude to that with social class, and the adverse effects of air pollution seem to be greater in men in lower social classes.     

Estimating CHD prevalence by small area: integrating information from health surveys and area mortality

The risk of coronary heart disease (CHD) is strongly linked both to deprivation and ethnicity and so prevalence will vary considerably between areas. Variations in prevalence are important in assessing health care needs and how far CHD service provision and surgical intervention rates match need. This paper uses a regression model of prevalence rates by age, sex, region and ethnicity from the 1999 and 2003 Health Surveys for England to estimate CHD prevalence for 354 English local authority areas. To allow for the impact of social factors on prevalence, survey information on the deprivation quintile in the respondents' micro-area of residence is also used. Allowance is also made for area CHD mortality rates (obtained from aggregated vital statistics data) which are positively correlated with, and hence a proxy for, CHD prevalence rates. An application involves assessment of surgical intervention rates in relation to prevalence at the level of 28 Strategic Health Authorities.     

Gender differences in structural and behavioral determinants of health: an analysis of the social production of health

This paper explores aspects of the social production of health by focussing on the ways in which levels of health are shaped by structures of social inequality and behaviors or 'lifestyles'. We address two questions: What is the relative importance of the social, structural and behavioral determinants of health? And, are there gender differences in the determinants of health? These questions are explored using multiple regression analyses of data from the 1994 Canadian National Population Health Survey. Two measures of health are used: subjective health status and the Health Utilities Index (a measure of functional health status). By structural determinants we refer to age, family structure, main activity, education, occupation, income and social support. Behavioral determinants include lifestyle factors related to smoking, drinking, weight and physical activity. Findings indicate that the structures of social inequality are the most important determinants of health acting both independently and through their influence on the behavioral determinants of health. There are very real differences in the factors that predict women's and men's health. For women, social structural factors appear to play a more important role in determining health. Being in the highest income category, working full-time and caring for a family and having social support are more important predictors of good health for women than men. Smoking and alcohol consumption are more important determinants of health status for men than women, while body weight and being physically inactive are more important for women than men. Our findings suggest the value of models which include a wide range of structural and behavioral variables and affirm the importance of looking more closely at gender differences in the determinants of health.     

Critically examining diversity in end-of-life family caregiving: implications for equitable caregiver support and Canada’s Compassionate Care Benefit

Background

Mental health is of special importance regarding socioeconomic inequalities in health. On the one hand, mental health status mediates the relationship between economic inequality and health; on the other hand, mental health as an "end state" is affected by social factors and socioeconomic inequality. In spite of this, in examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and then to untangle and quantify the contributions of potential determinants of mental health to the measured socioeconomic inequality.

Methods

In a cross-sectional observational study, mental health data were taken from an Urban Health Equity Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and covering people aged 15 and above. Principal component analysis was used to measure the economic status of households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and decomposed into its determinants.

Results

The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057). Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence (12.5%) and employment status (6.5%) also proved further important contributors to the inequality.

Conclusions

Socioeconomic inequalities exist in mental health status in Iran's capital, Tehran. Since the root of this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of mental health.     

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.     

Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health

The Commission on the Social Determinants of Health (CSDH) was established to advise on ways in which understanding of the social determinants of health can affect practical action to improve population health equitably. This paper considers the factors that are necessary to encourage governments to adopt policies that aim at doing this. It argues that knowledge, while essential, is insufficient. Governments need a commitment to the values of fairness and justice and an ability to cope with the complexity of responding to social determinants beyond exhorting individuals to change their behaviour. The role of civil society is crucial in advocating for governments to do this. The presence of linking social capital is also crucial to creating a social and political environment in which fairness is promoted. A case study of the poor health status of the Aboriginal peoples in Australia is used to illustrate the importance of social capital.     

Average household income, crime, and smoking behaviour in a local area: the Finnish 10-Town study

Social environments, like neighbourhoods, are increasingly recognised as determinants of health. While several studies have reported an association of low neighbourhood socio-economic status with morbidity, mortality and health risk behaviour, little is known of the health effects of neighbourhood crime rates. Using the ongoing 10-Town study in Finland, we examined the relations of average household income and crime rate measured at the local area level, with smoking status and intensity by linking census data of local area characteristics from 181 postal zip codes to survey responses to smoking behaviour in a cohort of 23,008 municipal employees. Gender-stratified multilevel analyses adjusted for age and individual occupational status revealed an association between low local area income rate and current smoking. High local area crime rate was also associated with current smoking. Both local area characteristics were strongly associated with smoking intensity. Among ever-smokers, being an ex-smoker was less likely among residents in areas with low average household income and a high crime rate. In the fully adjusted model, the association between local area income and smoking behaviour among women was substantially explained by the area-level crime rate. This study extends our knowledge of potential pathways through which social environmental factors may affect health.     

Income inequality, social capital and self-rated health and dental status in older Japanese

The erosion of social capital in more unequal societies is one mechanism for the association between income inequality and health. However, there are relatively few multi-level studies on the relation between income inequality, social capital and health outcomes. Existing studies have not used different types of health outcomes, such as dental status, a life-course measure of dental disease reflecting physical function in older adults, and self-rated health, which reflects current health status. The objective of this study was to assess whether individual and community social capital attenuated the associations between income inequality and two disparate health outcomes, self-rated health and dental status in Japan. Self-administered questionnaires were mailed to subjects in an ongoing Japanese prospective cohort study, the Aichi Gerontological Evaluation Study Project in 2003. Responses in Aichi, Japan, obtained from 5715 subjects and 3451 were included in the final analysis. The Gini coefficient was used as a measure of income inequality. Trust and volunteering were used as cognitive and structural individual-level social capital measures. Rates of subjects reporting mistrust and non-volunteering in each local district were used as cognitive and structural community-level social capital variables respectively. The covariates were sex, age, marital status, education, individual- and community-level equivalent income and smoking status. Dichotomized responses of self-rated health and number of remaining teeth were used as outcomes in multi-level logistic regression models. Income inequality was significantly associated with poor dental status and marginally significantly associated with poor self-rated health. Community-level structural social capital attenuated the covariate-adjusted odds ratio of income inequality for self-rated health by 16% whereas the association between income inequality and dental status was not substantially changed by any social capital variables. Social capital partially accounted for the association between income inequality and self-rated health but did not affect the strong association of income inequality and dental status.     

Migration and ethnicity, environmental factors important for children's health

The consideration of the social environment, living conditions, exposure to environmental hazards, and health behavior provide useful aspects for assessing and improving the health status of children. Migration-related factors, cultural background and ethnicity are important determinants of environmental health.     

Action on the social determinants of health: A historical perspective

Abstract

A renewed concern with social factors has emerged in global public health, spearheaded by the World Health Organization's Commission on Social Determinants of Health. The coming decade may see significant health gains for disadvantaged populations if policies tackle the social roots of health inequities. To improve chances of success, global action on social determinants must draw lessons from history. This article reviews milestones in public health action on social determinants over the past 50 years. The goal is to bring into sharper focus the persistent challenges faced by social determinants agendas, along with distinctive opportunities now emerging. The historical record highlights the vulnerability of health policy approaches incorporating social determinants to resistance from entrenched interests. The Commission on Social Determinants of Health can consolidate political support by building collaborative relationships with policymakers in partner countries. However, this strategy must be complemented by engaging civil society constituencies. Historically, successful action on social determinants has been spurred by organized civil society demand.