Abstract
BackgroundInequalities in the distribution of the social determinants of health are now a widely recognised problem, seen as requiring immediate and significant action (CSDH. Closing the Gap in a Generation. Geneva: WHO; 2008; Marmot M. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalitites inEngland Post-2010. London; 2010). Despite recommendations for action on the social determinants of health dating back to the 1980s, inequalities in many countries continue to grow. In this paper we provide an analysis of recommendations from major social determinants of health reports using the concept of ‘system leverage points’. Increasingly, powerful and effective action on the social determinants of health is conceptualised as that which targets government action on the non-health issues which drive health outcomes.MethodsRecommendations for action from 6 major national reports on the social determinants of health were sourced. Recommendations from each report were coded against two frameworks: Johnston et al’s recently developed Intervention Level Framework (ILF) and Meadow’s seminal ‘12 places to intervene in a system’ (Johnston LM, Matteson CL, Finegood DT. Systems Science and Obesity Policy: A Novel Framework forAnalyzing and Rethinking Population-Level Planning. American journal of public health. 2014;(0):e1-e9; Meadows D. Thinking in Systems. USA: Sustainability Institute; 1999) (N = 166).ResultsOur analysis found several major changes over time to the types of recommendations being made, including a shift towards paradigmatic change and away from individual interventions. Results from Meadow’s framework revealed a number of potentially powerful system intervention points that are currently underutilised in public health thinking regarding action on the social determinants of health.ConclusionWhen viewed through a systems lens, it is evident that the power of an intervention comes not from where it is targeted, but rather how it works to create change within the system. This means that efforts targeted at government policy can have only limited effectiveness if they are aimed at changing relatively weak leverage points. Our analysis raises further (and more nuanced) questions about what effective action on the social determinants of health looks like.
Highlights
Inequalities in the distribution of the social determinants of health are a widely recognised problem, seen as requiring immediate and significant action
Social determinants of health researchers have begun turning their attention to systems science to supply new insights into how to reduce the social inequalities that lead to health inequalities [8, 9]; “In order to understand drivers of population health outcomes and disparities, it is essential to learn about and understand the underlying systemic complexities that generate the outcomes we observe.” [10]
In this paper we provide an analysis of recommendations from major social determinants of health reports emerging from the UK and World Health Organisation (WHO), using the concept of ‘system leverage points’
Summary
Inequalities in the distribution of the social determinants of health are a widely recognised problem, seen as requiring immediate and significant action Inequalities in the distribution of the social determinants of health are a widely recognised problem, seen as requiring immediate and significant action [1, 2]. Since the Black Report’s release in 1980, representatives of public health have been making recommendations regarding how to best address inequalities in the social determinants of health [5]. These recommendations are uniformly directed to government, asking it to intervene in key areas – Despite numerous national and international reports urging action, inequalities in the social determinants of health continue to grow in many countries [6, 7]. The emphasis is placed on understanding the ‘whole’ system, rather than focusing exclusively on individual components [12,13,14, 16,17,18]
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