What has bioethics to offer health policy?

The field of bioethics has quickly become a subject of intense public fascination; and, following on an earlier period of resistance and skepticism, bioethics has been welcomed by clinicians as well. Bioethics, however, is largely a practical activity rather than a scholarly one, and its pretensions as an academic discipline within health policy and health services research must be greeted cautiously. Continuing problems in moral theory suggest that the most secure contributions that bioethics can make to health policy research are analysis and criticism rather than positive moral claims.     

The bioethics of protection and the state's role: moral problems in unequal access to drinking water

The aim of this study is to examine unequal access to drinking water as a public health problem in terms of normative and analytical tools in the bioethics of protection. Therefore, we analyze both the moral implications of unequal treatment of primary needs, such as situations of vulnerability and threat to population groups, and the public sector's responsibility in supplying safe water. In addition, solutions are proposed for the protection of public health and the promotion of legitimate personal development projects. The bioethics of protection reaffirms the state's role in maintaining the drinking water supply and recommends avoiding a policy of privatization of this public good, meanwhile justifying public policies to correct situations of social injustice.     

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.     

Ideology,obesity and the social determinants of health: a critical analysis of the obesity and health relationship

Based on a critical review of the obesity and health literature we provide five models of how the hypothesized obesity and health relationship is conceptualized. We then apply these models to make sense of how recent Canadian public health reports and clinical practice guidelines conceptualize the issue of obesity, its causes and health effects, and appropriate responses. We show how conformity to dominant models of the obesity and health relationship by health sciences researchers, public health workers, and the media lead to activities that rather than promoting health, actually threaten it. These dominant models – and the activities derived from them – do so by diverting attention from the far more important issues of the quality and distribution of the social determinants of health. These approaches also stigmatize heavy individuals, doing little to promote their health. For these reasons, we call for an end to seeing obesity as a significant health issue.     

Epidemiology and bioethics: a plea for reconnecting with the public

The author takes the position that both epidemiology and bioethics, as practiced within academic establishments, have largely although not entirely abstracted the public context of health and well-being from their respective disciplines. It is argued that by and large both disciplines have been highly successful at what they do. However, this success can in part be attributed to each limiting its ability to look beyond its respective academic niche and thus embrace challenges which are socially challenging, politically charged, and academically messy. This narrow focus has become self-serving and ultimately detracts from fundamental remits of both disciplines in protecting the public from harm. Furthermore, it may re-enforce the inequalities of research into health overall, whereby the greatest concentration of effort remains firmly focused upon those who already have the most. Currently marginalized approaches to each of these disciplines - such as social epidemiology, global bioethics, and critical bioethics - provide us with platforms that challenge mainstream academic epidemiologists and bioethicists to seek out and reconnect their expertise with questions that are more relevant to real-world situations.     

The determinants of First Nation and Inuit health: a critical population health approach

Environmental dispossession disproportionately affects the health of Canada's Aboriginal population, yet little is known about how its effects are sustained over time. We use a critical population health approach to explore the determinants of health in rural and remote First Nation and Inuit communities, and to conceptualize the pathways by which environmental dispossession affects these health determinants. We draw from narrative analysis of interviews with 26 Community Health Representatives (CHRs) from First Nation and Inuit communities across Canada. CHRs identified six health determinants: balance, life control, education, material resources, social resources, and environmental/cultural connections. CHRs articulated the role of the physical environment for health as inseparable from that of their cultures. Environmental dispossession was defined as a process with negative consequences for health, particularly in the social environment. Health research should focus on understanding linkages between environmental dispossession, cultural identity, and the social determinants of health.     

Human rights, an opportunity for public policies in health

Human rights outlined a better scenario for public policies in health. For it requires intersectoral and interdisciplinary approach. This article emphasizes the perspective of public health policies based on human rights, clarifies the relationship of public policies with the exercise of human rights, beyond the right to health. It recognizes the need to implement genuinely democratic and participatory mechanisms. It considers the universal declaration of human rights and other institutional expressions about the same as the international covenant on economic, social and cultural rights, discusses the ranking of the same and defend its entirety on the determinants of health through its cohesion and political factor. It defines a framework for public health and human rights that trend by strengthening social rights, as a new area of operation, based on public policies to address the determinants of health, upholding social justice, beyond the health field and the biological and behavioural risk factors to decisions arising from political power, exceeds medical solutions and access to health services. In conclusion, it promoting respect for human rights by greater understanding of them and strengthens the importance of indirect health policies (such as food, environment and health, violence gender) and the role of international policies in the global world.     

A proposed core model of the new public health for a healthier collectivity: how to sustain transdisciplinary and intersectoral partnerships

At present, there is no conceptual model by which public health could be represented as intersectoral governance collaborating with society and the state, and acting as a collective on the determinants of health. In this article, our interdisciplinary group, representing core competencies in public health, suggest two complementary conceptual models as frameworks for a diverse public concerned with public health and its core functions. The first conceptual ‘core model’ roots from the Ottawa Charter for Health Promotion. It represents the interrelationships of the three main poles united at the biopower level: the collectivity (entire population), the contemporary state and public health. In the second conceptual model, we present the various components in the meta-network of public health governance. We also present the roles of heterogeneous actors and how they can collaborate within a prominent process of capacity building and development of practice in public health. Thus, we emphasize the importance of intersectoral partnerships the contemporary state can make with public health without inducing any rupture with the social fabric. Our two complementary models can help actors from all sectors better understand the most frequent questions in public health governance (functions, roles, ingredients) and the challenges that intersectoral actors may very likely encounter in the implementation of these frameworks. The sustainability of well-balanced transdisciplinary and intersectoral partnerships contribute to a successful implementation of public health governance, and most importantly to a good health status for the collectivity.     

Adapting needs assessment methodologies to build integrated health pathways for people in the criminal justice system

Criminal justice health services should be underpinned with good public health evidence about the population's health needs. Health needs assessment methodologies can provide valuable intelligence for commissioners to evaluate the quality of services and innovate according to need. However, health needs assessment can be limited if it takes a conventional epidemiological approach, focussing on individuals' healthcare needs in criminal justice settings. Techniques used to measure health and social need could be more widely applied and appropriately employed in the planning of health and social care services, especially if the intention is to be effective in reducing social exclusion and tackling health inequalities. Assessment tools are available that capture individual, social and environmental risk factors and determinants predisposing people to health and criminogenic risks. Good evidence gathering can mean that public health practitioners not only improve health, reduce inequalities and tackle social exclusion, but contribute to reducing re-offending. This paper suggests a new approach to assessment that integrates the full range of assessment methodologies available to practitioners. An integrated approach may be the way to enhance and enrich the public health function in providing evidence to improve the quality of local public services.     

Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario,Canada: a qualitative inquiry

To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard’s concept of epistemological barriers and Raphael’s seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized.     

Opinions of students and educators concerning health: the public school perspective in a peripheral area of the city of São Paulo

This study focused on prevailing concepts in society concerning adolescents' health problems and needs. Based on concerns in the field of Collective Health in relation to public policies for social protection, the study attempted to grasp the public school perspective concerning these issues. The study's theoretical reference was the social determination of the health-disease process and the view that health needs are translated into demands for changes in the harmful processes resulting from relations in the production process. Data were gathered through interviews with pedagogical coordinators and focus groups with adolescents in public schools from the Raposo Tavares School District (Municipality of S o Paulo). The results showed that the participants recognized: (1) the sphere of social determinants at the base of adolescents' health problems and (2) in addition to disease processes, a set of social problems impacting the health-disease process, highlighting drug use and violence. Health needs are translated as demands for cross-sector public social policies.     

Meeting the information needs of the 'Health for all' challenge--lessons from Scotland

OBJECTIVE: To create a public health data resource for Scotland that is based on a socio-ecological model of the determinants of health and would, therefore, meets the needs of the emerging public health agenda. DESIGN: Action research, in which the approach moved logically through stages of action (conception, feasibility study, pilot projects, leading to a national set of integrated health and well-being profiles). Each stage built on the results of the previous research. RESULTS: The conceptual stage identified the need for an approach to public health data that kept pace with the increasingly accepted socio-ecological models of the determinants of health. A feasibility study concluded that sufficient data were available to populate the health fields that represented the important determinants of health. At this time strengths and weakness in data were defined. This led to the articulation of a 'vision' for integrated public heath data in Scotland that was the subject of a wide consultation. Pilot studies provided local stakeholders with imaginatively presented data (on population demographics, health and function, behaviour, social environment, economy, physical environment, morbidity and mortality) for their local communities. The response to these was so positive that a demand was created for a comprehensive set of 'community profiles'. These, in addition to parliamentary constituency profiles, have now been created and widely disseminated. CONCLUSIONS: It has been possible, despite many difficulties, to develop approaches to public health information that are informed by the socio-ecological model of health and create outputs that represent a significant advance on previous approaches to public health data. This is a work in progress and many issues remain unresolved. Interaction with others engaged in parallel tasks will facilitate the next steps.     

Barriers to addressing the social determinants of health: Insights from the Canadian experience

Despite Canada's reputation as a leader in health promotion and population health, implementation of public policies in support of the social determinants of health has been woefully inadequate. The continuing presence of income, housing, and food insecurity has led to Canada being the subject of a series of rebukes from the United Nations for failing to address child and family poverty, discrimination against women and Aboriginal groups, and most recently the crisis of homelessness and housing insecurity. In this article we consider some of the reasons why this might be the case. These include the epistemological dominance of positivist approaches to the health sciences, the ideology of individualism prevalent in North America, and the increasing influence on public policy of the marketplace. Various models of public policy provide pathways by which these barriers can be surmounted. Considering that the International Commission on the Social Determinants of Health will soon be releasing its findings and recommendations, such an analysis seems especially timely for understanding both the Canadian scene and developments in other nations.     

Barriers to addressing the social determinants of health: insights from the Canadian experience

Despite Canada's reputation as a leader in health promotion and population health, implementation of public policies in support of the social determinants of health has been woefully inadequate. The continuing presence of income, housing, and food insecurity has led to Canada being the subject of a series of rebukes from the United Nations for failing to address child and family poverty, discrimination against women and Aboriginal groups, and most recently the crisis of homelessness and housing insecurity. In this article we consider some of the reasons why this might be the case. These include the epistemological dominance of positivist approaches to the health sciences, the ideology of individualism prevalent in North America, and the increasing influence on public policy of the marketplace. Various models of public policy provide pathways by which these barriers can be surmounted. Considering that the International Commission on the Social Determinants of Health will soon be releasing its findings and recommendations, such an analysis seems especially timely for understanding both the Canadian scene and developments in other nations.     

Public Health Strategies to Address Asian Men's Health Needs

Men's health discourse has been around for more than 2 decades. The higher mortality rates and the shorter life expectancy in Asian men compared with their women counterparts show the disadvantaged status of men's health. Thus, discussions on men's health should address their health needs and not be confined to sex-specific male urology and reproductive health. In Asia, assessing men's health needs is challenging because of the vast differences in the socioeconomic status and the diverse culture among its member countries. Although, the epidemiology of men's health provides the focus for what to address in improving men's health, having an optimal strategy requires the understanding of men's health-seeking behaviors and the social determinants surrounding them. Thus, public health approaches addressing health behaviors and health promotion in the society should be one of the keys in improving men's health status. Locally relevant information is needed to inform effective public health approaches.     

Public-Health-Ethik

The international discourse about public health ethics is becoming more intensive and complex. The starting point is bioethics. The debate about public health ethics is simultaneously a debate about an adequate identity of public health, its goals, tasks and standards. In Germany there is a tremendous need to take part in this discourse. German experiences within the traditions of social medicine, social hygiene and medical ethics could significantly contribute to the international discussion. Unfortunately the German speaking public health community has hardly acknowledged the topic of ethics. The reasons for this are not explicitly known. The Anglo-American discourse is much more developed, but the concepts, terms and paradigms should not simply be transferred. They should critically be proven.     

Health promotion: a global perspective

The first part of this paper reviews the work of the World Health Organization's Regional Office for Europe undertaken to clarify the relevance of health promotion for all member states and regions. This work led to a definition of "health" as the ability to realize aspirations and satisfy needs and to change or cope with the environment. Health promotion was considered to 1) involve the population as a whole in the context of everyday lives, 2) be directed towards action on the determinants of health, 3) combine diverse but complementary methods or approaches, 4) aim for effective and concrete public participation, and 5) involve health professionals. Areas covered by health promotion activities include 1) access to health, 2) development of an environment conductive to health, 3) strengthening of social networks and social supports, 4) promoting positive health behavior and appropriate coping strategies, and 5) increasing knowledge and disseminating information. The next section of the paper traces the development of the concept of health promotion from its roots in health education, and the third section presents a brief history of public health to contextualize this development. The differences between the old and new approaches to public health are presented (the new role of the health sector is to ensure access to health, create advocacy for health, and move beyond health care through intersectoral action and public participation), and the new "forcefield" of public health that emerges from a conceptualization of health promotion is described. This forcefield, illustrated as a triangle linking healthy public policy, health promotion, and community action, works at all levels and is the framework for the development of appropriate strategies. It is concluded that in many cases public health will have to be reorganized as will the health care system as a whole. Health must be viewed as a social project linked to political responsibilities not as a medical enterprise.     

‘The pitfalls of the “add-and-stir” approach to transdisciplinary public health research’

Health researchers increasingly include social scientific disciplines in their research programs, partly as a result of increasing recognition that complex public health issues benefit from a range of research approaches, and partly because funding bodies increasingly require transdisciplinarity. This commentary addresses the role of epistemology in transdisciplinary public health research (TPHR). We discuss two problems with current TPHR. The first problem is that social scientific input into TPHR is typically circumscribed to social, cultural, economic, and political analyses of a given public health issue, and further that these analyses only use social constructivist epistemologies. This narrow delineation under-utilizes a valuable, yet largely untapped resource; namely, various realist epistemologies regularly employed by social scientists, which are typically committed to anti-reductive and non-social constructivist understandings of scientific practices and knowledge. The second problem is the paucity of meta-analyses of the tacit epistemological cultures driving transdisciplinary research teams. The advantage of such meta-analyses is that they are able to make epistemologies explicit, which is the first step in actually integrating knowledge from different academic disciplines. Given that epistemological commitments guide research agendas – from what questions are asked and what methodologies are selected, to how findings are interpreted – understanding the role of epistemology stands to make an important contribution to improving TPHR.     

Mainstream media and the social determinants of health in Canada: is it time to call it a day?

This article explores the dearth of coverage of the social determinants of health by the Canadian mainstream media. It is argued that this neglect is primarily a reflection of political and economic societal structures that has been associated with increasing corporate control of the mainstream media. Applying a critical political economy lens, it is argued that the barriers to having the Canadian mainstream media report on the social determinants of health are so numerous that it may indeed be 'time to call it a day' in regard to having them assist in the dissemination of social determinants of health findings. Recognizing this reality should spur the development of alternative means of communicating with the public in order to develop a citizens' movement to create health-promoting public policy. Recent dissemination efforts related to the Social Determinants of Health: The Canadian Facts provide an example of how this might be accomplished.