Critical Social Determinants Of Health Research Articles

Decomposing socio-economic inequalities in antenatal care utilisation in 12 Southern African Development Community countries

Although many countries are making progress towards achieving the global sustainable development goals, sub-Saharan Africa (SSA) lags behind. SSA bears a relatively higher burden of maternal morbidity and mortality than other regions despite existing cost-effective interventions. This paper assesses antenatal care (ANC) service utilisation among women in the Southern African Development Community (SADC) countries, one of the four SSA regions. Specifically, it assesses socioeconomic inequality in the number of ANC visits, use of no ANC service, between one and three ANC visits and at least four ANC visits, previously recommended by the World Health Organization (WHO). Data come from the most recent Demographic and Health Surveys in twelve SADC countries. Wagstaff's normalised concentration index (CI) was used to assess socioeconomic inequalities. Factors explaining these inequalities were assessed using a standard method and similar variables contained in the DHS data. A positive CI means that the variable of interest is concentrated among wealthier women, while a negative CI signified the opposite. The paper found that wealthier women in the SADC countries are generally more likely to have more ANC visits than their poorer counterparts. Apart from Zambia, the CIs were positive for inequalities in at least 4 ANC visits and negative for between 1 and 3 ANC visits. Women from poorer backgrounds significantly report no ANC visits than wealthier women. Apart from the portion that was not explainable due to limitations in the variables included in the model, critical social determinants of health, including wealth, education and the number of children, explain socioeconomic inequalities in ANC coverage in SADC. A vital policy consideration is not to leave any woman behind. Therefore, addressing access barriers and critical social determinants of ANC inequalities, such as women's education and economic well-being, can potentially redress inequalities in ANC coverage in the SADC region.

Six ways to help fix energy hardship in New Zealand

Energy hardship is caused by the interaction of factors including housing quality, appliance efficiency, energy source and price, and occupant needs and income. Multiple policy approaches are needed to address these varied causes of energy hardship, and the lack of an official definition and a measurement strategy in Aotearoa should not preclude policy action to address this critical social determinant of health. Here we outline six ways to help fix energy hardship in New Zealand.

Child vaccination in sub-Saharan Africa: Increasing coverage addresses inequalities

BackgroundVaccines have substantially contributed to reducing morbidity and mortality among children, but inequality in coverage continues to persist. In this study, we aimed to examine inequalities in child vaccination coverage in sub-Saharan Africa. MethodsWe analysed Demographic and Health Survey data in 25 sub-Saharan African countries. We defined full vaccination coverage as a child who received one dose of bacille Calmette-Guérin vaccine (BCG), three doses of diphtheria, pertussis, and tetanus vaccine (DTP 3), three oral polio vaccine doses (OPV 3), and one dose of measles vaccine. We used the concentration index (CCI) to measure wealth-related inequality in full vaccination, incomplete vaccination, and zero-dose children within and between countries. We fitted a multilevel regression model to identify predictors of inequality in receipts of full vaccination. ResultsOverall, 56.5% (95% CI: 55.7% to 57.3%) of children received full vaccination, 35.1% (34.4% to 35.7%) had incomplete vaccination, while 8.4% (95% CI: 8.0% to 8.8%) of children remained unvaccinated. Full vaccination coverage across the 25 sub-Saharan African countries ranged from 24% in Guinea to 93% in Rwanda. We found pro-rich inequality in full vaccination coverage in 23 countries, except for Gambia and Namibia, where we found pro-poor vaccination coverage. Countries with lower vaccination coverage had higher inequalities suggesting pro-rich coverage, while inequality in unvaccinated children was disproportionately concentrated among disadvantaged subgroups. Four or more antenatal care contracts, childbirth at health facility, improved maternal education, higher household wealth, and frequently listening to the radio increased vaccine uptake. ConclusionsContinued efforts to improve access to vaccination services are required in sub-Saharan Africa. Improving vaccination coverage and reducing inequalities requires enhancing access to quality services that are accessible, affordable, and acceptable to all. Vaccination programs should target critical social determinants of health and address barriers to better maternal health-seeking behaviour.

Food Insecurity Is Prevalent in Iowa’s Medicaid Expansion Population

BackgroundFood insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. ObjectiveOur objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa’s Medicaid expansion population. DesignWe conducted a cross-sectional telephone survey between March and May of 2019. ParticipantsOur sample was drawn from Medicaid members enrolled in Iowa’s expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. Main outcome measureOur main outcome was whether a respondent’s household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. Statistical analyses performedWe weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. ResultsThe estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. ConclusionsOur findings show that food insecurity is prevalent in Iowa’s Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. AbbreviationsIowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP)

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors.

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Understanding the Nexus Between Alcohol Consumption, Social and Emotional Well-Being, and Higher Education Outcomes among Aboriginal and Torres Strait Islander Males in Australia

Education is a critical social determinant of health, particularly in the context of Aboriginal and Torres Strait Islander health and well-being. There is also a broad array of other health risk factors that intersect with these social and cultural determinants of health. Overall, an in-depth examination of the complex health–education nexus is needed. This paper provides a commentary on interrelationships between health risk factors, their impact on education trajectories, and their implications for Aboriginal and Torres Strait Islander males.

Social Cohesion in Health: A Concept Analysis.

The concept of social cohesion has been indicated to be a critical social determinant of health in recent literature. Inconsistencies surrounding the conceptualization and operationalization have made utilizing these findings to inform health intervention and policy difficult. The objective of this article is to provide a theoretical clarification of the concept "social cohesion," as it relates to health behaviors and outcomes by using the Rodgers' evolutionary method for concept analyses. This article uncovers the critical attributes, antecedents, and consequences of social cohesion and provides reflection on future use of social cohesion in health literature.

Food as a Critical Social Determinant of Health Among Older Adults During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Coronavirus Disease 2019 Has Worsened Food Insecurity Among Families With Low Incomes, but Medicaid Is a “Potential Vehicle” for Relief

Social determinants of health: the role of effective communication in the COVID-19 pandemic in developing countries

ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic has affected many countries with increasing morbidity and mortality. Interestingly, many of the actions and policies adopted in countries are linked to the social determinants of health (SDH). The SDH are critical determinants of health and health inequalities that are not directly within the health sector. Policies such as social distancing, good hygiene, avoiding large gatherings, cancelling of social and sports events, using personal protective equipment, schools and restaurants closure, country lockdown, etc. are not necessarily within the health sector but have been promoted to prevent and attenuate COVID-19 infection rates significantly. The SDH that serve to reduce morbidity will forestall or substantially reduce the pressure on many weak health systems in developing countries that cannot cope with increased hospitalisation and intensive health care. This paper argues that one of the most critical social determinants of health (i.e. effective crisis and risk communication), is crucial in many developing countries, including those with fewer confirmed coronavirus cases. We note that the effectiveness of many of the other SDH in reducing the burden of the COVID-19 pandemic hinges on effective communication, especially crisis and risk communication. Although many countries are adopting different communication strategies during the COVID-19 crisis, effective crisis and risk communication will lead to building trust, credibility, honesty, transparency, and accountability. The peculiarity of many developing countries in terms of regional, cultural, linguistic and ethnic diversity is an essential consideration in ensuring effective crisis and risk communication. Developing countries facing significant poverty and disease burden cannot afford to handle the burgeoning of COVID-19 infections and must take preventive measures seriously. Thus, we submit that there is a need to intensify SDH actions and ensure that no one is left behind when communicating crisis and risk to the population to address the COVID-19 pandemic.

Immigration Policy as a Social Determinant of Health: Development and Initial Validation of a Measure to Assess Attitudes toward Immigrant Integration

ABSTRACT Anti-immigrant policymaking in the U.S. is a critical social determinant of health compromising the wellbeing of immigrants and, by extension, communities of color. It is imperative that social work, public health, and other allied professions unite to address anti-immigrant policymaking by improving intergroup attitudes and building broader public support for immigrant integration. This study fills a gap in the literature by psychometrically developing and initially validating a measure of attitudes toward integrationist immigration policymaking. A three-stage study was conducted to explore, calibrate, and validate the factor structure using exploratory and confirmatory factor analysis. Findings suggest there are two distinct but interrelated dimensions of attitudes toward integrationist immigration policies: support for the (a) extension of pathways to legal status and (b) expansion of eligibility for social rights and benefits. Initial evidence of criterion validity for the scale is offered. The utility of the measure for intergroup intervention testing is discussed.

A call to action for community/public health nurses: Treat structural racism as the critical social determinant of health it is

A call to action for community/public health nurses: Treat structural racism as the critical social determinant of health it is

Residential moves and its association with substance use, healthcare needs, and acute care use among homeless and vulnerably housed persons in Canada.

To determine the relationship between housing instability, as measured by the number of residential moves, with problematic substance use, unmet healthcare needs, and acute care utilization. A cohort of homeless or vulnerably housed persons from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396) completed interviewer-administered surveys at baseline and annually for 4years from 2009 to 2013. Generalized mixed effects logistic regression models were used to examine the association between the number of residential moves and each of the three outcome variables, adjusting for potential confounders. The number of residential moves was significantly associated with higher acute care utilization [adjusted odds ratio (AOR) 1.25; 95% confidence interval (CI) CI: 1.17-1.33], unmet healthcare needs (AOR 1.14; 95% CI: 1.07-1.22), and problematic substance use (AOR 1.26; 95% CI: 1.16-1.36). Having chronic physical or mental conditions and recent incarceration were also found to be associated with the outcomes. Housing instability increased the odds of all three poor health metrics, highlighting the importance of stable housing as a critical social determinant of health.

Adding a Vital Sign: Considering the Utility of Place-Based Measures in Health Care Settings.

During rounds, you prepare to enter the room of a child who was hospitalized overnight for an asthma exacerbation. You review the chart, taking careful notice of the documented history and the physical examination. You also quickly glance at the child’s zip code. This may not be a routine aspect of your care, but this particular zip code stands out. You know that it includes blocks with dilapidated housing conditions, limited access to pharmacies, and unreliable bus routes. You wonder whether this is the reality faced by your patient. This prompts you to more deeply consider your management plans for this child’s hospitalization and for their eventual transition to home. How could or should you think about this child’s zip code in relation to their medical and social needs? Is it a proxy for their own risks or a reflection of their surroundings? Or is it both? With studies in which measures of a child’s neighborhood are linked to adverse postdischarge outcomes1 and to patient-level social and financial risks themselves,2 it is becoming increasingly relevant to consider how to interpret and then use such measures during clinical care. As hospitalists grapple with such scenarios and questions, they may begin by considering the extent to which place-based measures, or “geomarkers,”3 may or may not serve as proxies for patient-level social, economic, and environmental risks. Geomarkers can approximate risks related to critical social determinants of health (SDH) that are known to be associated with poor health outcomes for conditions like pediatric asthma (eg, readmission).2,4,5 Still, such place-based measures are not commonly used during clinical encounters. This is despite …

Shelter from the Storm: Roles, responsibilities, and challenges in United States housing policy governance

Housing is a critical social determinant of health. Housing policy not only affects health by improving housing quality, affordability, and insecurity; housing policy affects health upstream through the politics that shape housing policy design, implementation, and management. These politics, or governance strategies, determine the successes or failures of housing policy programs. This paper is an overview of challenges in housing policy governance in the United States. I examine the important relationship between housing and health, and emphasize why studying housing policy governance matters. I then present three cases of housing governance challenges in the United States, from each pathway by which housing affects health - housing quality, affordability, and insecurity. Each case corresponds to an arm of the TAPIC framework for evaluating governance (Krieger and Higgins) [1], to assess mechanisms of housing governance in each case. While housing governance has come a long way over the past century, political decentralization and the expansion of the submerged state have increased the number of political actors and policy conflict in many areas. This creates inherent challenges for improving accountability, transparency, and policy capacity. In many instances, too, reduced government accountability and transparency increases the risk of harm to the public and lessens governmental integrity.

Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries

BackgroundImportant inequalities in childhood vaccination coverage persist between countries and population groups. Understanding why some countries achieve higher and more equitable levels of coverage is crucial to redress these inequalities. In this study, we explored the country-level determinants of (1) coverage of the third dose of diphtheria-tetanus-pertussis- (DTP3) containing vaccine and (2) within-country inequalities in DTP3 coverage in 45 countries supported by Gavi, the Vaccine Alliance. MethodsWe used data from the most recent Demographic and Health Surveys (DHS) conducted between 2005 and 2014. We measured national DTP3 coverage and the slope index of inequality in DTP3 coverage with respect to household wealth, maternal education, and multidimensional poverty. We collated data on country health systems, health financing, governance and geographic and sociocultural contexts from published sources. We used meta-regressions to assess the relationship between these country-level factors and variations in DTP3 coverage and inequalities. To validate our findings, we repeated these analyses for coverage with measles-containing vaccine (MCV). ResultsWe found considerable heterogeneity in DTP3 coverage and in the magnitude of inequalities across countries. Results for MCV were consistent with those from DTP3. Political stability, gender equality and smaller land surface were important predictors of higher and more equitable levels of DTP3 coverage. Inequalities in DTP3 coverage were also lower in countries receiving more external resources for health, with lower rates of out-of-pocket spending and with higher national coverage. Greater government spending on heath and lower linguistic fractionalization were also consistent with better vaccination outcomes. ConclusionImproving vaccination coverage and reducing inequalities requires that policies and programs address critical social determinants of health including geographic and social exclusion, gender inequality and the availability of financial protection for health. Further research should investigate the mechanisms contributing to these associations.

Action on the social determinants of health: Views from inside the policy process

It is now well documented that many of the key drivers of health reside in our everyday living conditions. In the last two decades, public health has urged political action on these critical social determinants of health (SDH). As noted by the World Health Organisation, encouraging action in this area is challenging. Recent research has argued that public health researchers need to gain a deeper understanding of the complex and changing rationalities of policymaking. This, it seems, is the crucial next step for social determinants of health research.In this paper, we turn our attention to the practitioners of ‘the art of government’, in order to gain insight into how to secure upstream change for the SDH. Through interviews with policy actors (including politicians, senior government advisors, senior public servants and experienced policy lobbyists) the research sought to understand the nature of government and policymaking, as it pertains to action on the SDH. Through exploring the policy process, we examine how SDH discourses, evidence and strategies align with existing policy processes in the Australian context.Participants indicated that approaches to securing change that are based on linear conceptualisations of the policy process (as often found in public health) may be seen as ‘out of touch’ with the messy reality of policymaking. Rather, a more dialogic approach that embraces philosophical and moral reasoning (alongside evidence) may be more effective. Based on our findings, we recommend that SDH advocates develop a deeper awareness of the political and policy structures and the discursive conventions they seek to influence within specific settings.

You can’t walk or bike yourself out of the health effects of poverty: active school transport, child obesity, and blind spots in the public health literature

Mainstream public health theories of obesity attribute current, unprecedented numbers of obese youth to changes in eating practices and levels of physical activity, in turn leading to greater energy consumption and lesser energy expenditure. While substantial research has examined energy consumption among school-age children, key modes of energy expenditure such as active school transport (AST) remain underexplored. Using AST data obtained from the California Safe Routes to Schools program and child health data from the California Physical Fitness Test, we examined the association between AST and child obesity among school-age children and disambiguated this relationship introducing the variable poverty. We found that greater AST correlated with higher rates of child obesity and higher rates of child poverty, which in turn correlated with worse child health and obesity rates. Our findings suggest that child poverty explains the positive relationship between AST and child obesity that has puzzled investigators. Our analysis also reveals recurring blind spots in the public health literature, which often acknowledges that poverty begets poor health yet calls for environmental changes while rarely calling for eliminating poverty, one critical social determinant of health, even as these determinants have become legitimate objects of scientific inquiry. We propose that while environmental changes may improve the health of the poor, the only effective way to improve child health and reduce child obesity is to eliminate or dramatically reduce child poverty, a sociopolitical issue. This study is part of a larger project evaluating socio-political determinants of child health.

The challenge of promoting interventions to prevent disease in impoverished populations in rural western Kenya.

Poverty is a critical social determinant of health. A particular approach toward mitigating inequitable access to health services in Kenya has been through a community-based distribution program implemented by the Safe Water and AIDS Project (SWAP) that has achieved modest uptake of public health interventions. To explore reasons for modest uptake, we asked program participants about child health problems, daily tasks, household expenditures, and services needed by their communities. Respondents identified child health problems consistent with health data and reported daily tasks, expenses, and needed services that were more related to basic needs of life other than health. These findings highlight the challenges of implementing potentially self-sustaining preventive interventions at scale in poor populations in the developing world.

Using a social marketing framework to evaluate recruitment of a prospective study of genetic counseling and testing for the deaf community

BackgroundRecruiting deaf and hard-of-hearing participants, particularly sign language-users, for genetics health service research is challenging due to communication barriers, mistrust toward genetics, and researchers’ unfamiliarity with deaf people. Feelings of social exclusion and lack of social cohesion between researchers and the Deaf community are factors to consider. Social marketing is effective for recruiting hard-to-reach populations because it fosters social inclusion and cohesion by focusing on the targeted audience’s needs. For the deaf population this includes recognizing their cultural and linguistic diversity, their geography, and their systems for information exchange. Here we use concepts and language from social marketing to evaluate our effectiveness to engage a U.S. deaf population in a prospective, longitudinal genetic counseling and testing study.MethodsThe study design was interpreted in terms of a social marketing mix of Product, Price, Place, and Promotion. Price addressed linguistic diversity by including a variety of communication technologies and certified interpreters to facilitate communication; Place addressed geography by including community-based participation locations; Promotion addressed information exchange by using multiple recruitment strategies. Regression analyses examined the study design’s effectiveness in recruiting a culturally and linguistically diverse sample.Results271 individuals were enrolled, with 66.1% American Sign Language (ASL)-users, 19.9% ASL + English-users, 12.6% English-users. Language was significantly associated with communication technology, participation location, and recruitment. Videophone and interpreters were more likely to be used for communication between ASL-users and researchers while voice telephone and no interpreters were preferred by English-users (Price). ASL-users were more likely to participate in community-based locations while English-users preferred medically-based locations (Place). English-users were more likely to be recruited through mass media (Promotion) while ASL-users were more likely to be recruited through community events and to respond to messaging that emphasized inclusion of a Deaf perspective.ConclusionsThis study design effectively engaged the deaf population, particularly sign language-users. Results suggest that the deaf population’s cultural and linguistic diversity, geography, and forms of information exchange must be taken into account in study designs for successful recruitment. A social marketing approach that incorporates critical social determinants of health provides a novel and important framework for genetics health service research targeting specific, and hard-to-reach, underserved groups.

Public health in the Canadian Arctic: contributions from International Polar Year research

The contributions of several IPY health projects are highlighted in the context of population health indicators for Inuit Nunangat. Food and housing are two critical social determinants of health contributing to health issues on many levels. The nutritional deficit associated with food insecurity and the transition away from traditional and towards market foods represents a dual risk with profound consequences. Knowledge of the physiological benefits associated with traditional food consumption is increasing, including for mental health and chronic disease. Ensuring the safety of traditional foods in terms of zoonotic diseases is thus highly valuable and efforts to institute adequate monitoring and address knowledge gaps are underway. Acute respiratory disease among the young remains a significant public health issue with potential long term effects. The human papilloma virus is manifesting itself among women across northern Canada with high risk types that are more similar to profiles observed in Europe than in North America with possible implications for immunization programs. Despite a high prevalence of Hepatitis B virus infections among residents of Inuit Nunangat, the outcomes appear to be relatively benign. Communication of new knowledge on the manifestation of this virus among northern populations is provided to health care providers in the North through modern technology.