From awareness to action on the social determinants of health

Abstract

The following editorial continues the series of editorials in the International Journal of Public Health on the WHO Commission Report on the Social Determinants of Health (CSDH, WHO 2008; Siegrist 2008; Vagero 2008; McQueen 2009; Koskinen and Puska 2009; Potvin 2009; MadarasovaGeckova 2009). In its final principle of action, the WHO Commission (CSDH) recognized the need to raise public awareness of the social determinants of health. Raised awareness should consist, according to the report, of a better understanding among actors, practitioners, and the general public of how population health is affected by social determinants (WHO 2008). Raised awareness may be the first step on a long path to action on the social determinants of health ultimately improving the public’s capacity for action (Madarasova-Geckova 2009). Yet, to close the gap will require more than raised awareness, it will require community-based action in a variety of forms. To contribute more broadly to the development of diverse communitybased initiatives in addressing the social determinants of health, the CSDH could have recognized a wider range of health promotion strategies within the report. Within the health promotion literature, there are a range of approaches and strategies for considering how to facilitate group and community willingness to address the social determinants of health. These range from more cooperative and collaborative models to those that assume more of a political conflict perspective. The relevance and appropriateness of specific approaches and strategies are context specific, and there is no one size that fits all. With these ideas in mind, it is worth considering certain assumptions about community action favored within the report. The CSDH report assumes that raised awareness about the social determinants of health will lead politicians and community groups to cooperate and work together in bringing about change. Using the analogy of a ‘‘nutcracker effect,’’ the commission describes the cracking of health inequity as coming from the cooperative action and joint pressure of top-down policy making and bottom-up community action (WHO 2008). To what degree does raised awareness translate into action? At the community level, research is mixed in support of this assumption. In Canada, an association between individual recognition of the structural causes of health inequities and a person’s willingness to support social policies to address those inequalities has been found Reutter et al. 2002). In the United States, however, it was recently shown that a person’s receptivity to a message on the social determinants of health is conditioned in part by their prior political beliefs (Gollust et al. 2009). After being exposed to a social determinants framing on a message about diabetes, Democrats expressed a higher level of support for public health policies, while Republicans expressed a lower level (Gollust et al. 2009). Advocates seeking to mobilize broad public support to address health Spencer Moore is Assistant Professor in the School of Kinesiology and Health Studies at Queen’s University, Kingston, Ontario, and Researcher at the centre de recherche du Centre Hospitalier de l’Universite de Montreal. He also holds a New Investigator Award from the Institute of Aging of the Canadian Institutes of Health Research.