Abstract
The field of public health has increasingly promoted a social ecological approach to health, shifting from an individual, biomedical paradigm to a recognition of social and structural determinants of health and health equity. Yet despite this shift, public health research and practice continue to privilege individual- and interpersonal-level measurements and interventions. Rather than adapting public health practice to social ecological theory, the field has layered new concepts (“root causes,” “social determinants”) onto a biomedical paradigm—attempting to answer questions presented by the social ecological schema with practices developed in response to biomedicine. This stymies health equity work before it begins—limiting the field's ability to broaden conceptions of well-being, redress histories of inequitable knowledge valuation, and advance systems-level change. To respond effectively to our knowledge of social determinants, public health must resolve the ongoing disconnect between social ecological theory and biomedically-driven practice. To that end, this article issues a clarion call to complete the shift from a biomedical to a social ecological paradigm, and provides a basis for moving theory into practice. It examines biomedicine's foundations and limitations, glosses existing critiques of the paradigm, and describes health equity challenges presented by over-reliance on conventional practices. It then offers theoretical and epistemological direction for developing innovative social ecological strategies that advance health equity.
Highlights
Advancing health equity relies upon understanding the central role of social determinants of health in influencing individuals’ contexts, options, and behaviors—and their health outcomes
Researchers and practitioners are likely to graft new concepts (“root causes,” “social determinants”) into the existing biomedical structure—attempting to answer questions presented by the social ecological schema with practices developed in response to biomedicine
The field’s uptake of the social ecological model, and its continued engagement with upstream drivers of health, indicates a window of opportunity to challenge the limitations of the biomedical paradigm—including the problems, research questions, and health-advancement opportunities its entrenchment has obscured
Summary
Advancing health equity relies upon understanding the central role of social determinants of health in influencing individuals’ contexts, options, and behaviors—and their health outcomes. Research (and subsequent practice) continue to privilege individualand interpersonal-level intervention, as evidenced by the prevailing gold standard of the randomized controlled trial, the disproportionate development and teaching of individual-level behavior theories in public health education, and the expectation among funders that measurable results at the individual level will be available within relatively short timeframes. This theory-practice dissonance in public health has generated slow progress to innovate and intervene at outer levels of the social ecological model, inabilities to access and respond to diverse knowledges, and, failures to advance health equity [see [8]]
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