Determinants Of Health In Order Research Articles

Addressing health inequity during the COVID-19 pandemic through primary health care and public health collaboration: a multiple case study analysis in eight high-income countries

BackgroundThe COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions.MethodsWe analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021.ResultsFour themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries.ConclusionsThis study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Essential Principles to Create an Equitable, Inclusive, and Diverse EMS Workforce and Work Environment: A Position Statement and Resource Document

POSITION STATEMENT Emergency medical services (EMS), similar to all aspects of health care systems, can play a vital role in examining and reducing health disparities through educational, operational, and quality improvement interventions. Public health statistics and existing research highlight that patients of certain socioeconomic status, gender identity, sexual orientation, and race/ethnicity are disproportionately affected with respect to morbidity and mortality for acute medical conditions and multiple disease processes, leading to health disparities and inequities. With regard to care delivery by EMS, research demonstrates that the current attributes of EMS systems may further contribute to these inequities, such as documented health disparities existing in EMS patient care management, and access along with EMS workforce composition not being representative of the communities served influencing implicit bias. EMS clinicians need to understand the definitions, historical context, and circumstances surrounding health disparities, health care inequities, and social determinants of health in order to reduce health care disparities and promote care equity. This position statement focuses on systemic racism and health disparities in EMS patient care and systems by providing multifaceted next steps and priorities to address these disparities and workforce development. NAEMSP believes that EMS systems should: Adopt a multifactorial approach to workforce diversity implemented at all levels within EMS agencies. Hire more diverse workforce by intentionally recruiting from marginalized communities Increase EMS career pathway and mentorship programs within underrepresented minorities (URM) communities and URM-predominant schools starting at a young age to promote EMS as an achievable profession. Examine policies that promote systemic racism and revise policies, procedures, and rules to promote a diverse, inclusive, and equitable environment. Involve EMS clinicians in community engagement and outreach activities to promote health literacy, trustworthiness, and education. Require EMS advisory boards whose composition reflects the communities they serve and regularly audit membership to ensure inclusion. Increase knowledge and self-awareness of implicit/unconscious bias and acts of microaggression through established educational and training programs (i.e., anti- racism, upstander, and allyship) such that individuals recognize and mitigate their own biases and can act as allies. Redesign structure, content, and classroom materials within EMS clinician training programs to enhance cultural sensitivity, humility, and competency and to meet career development, career planning, and mentoring needs, particularly of URM EMS clinicians and trainees. Discuss cultural views that affect health care and medical treatment and the effects of social determinants of health on care access and outcomes during all aspects of training. Design research and quality improvement initiatives related to health disparities in EMS that are focused on racial/ethnic and gender inequities and include URM community leaders as essential stakeholders involved in all stages of research development and implementation.

Integrating Social, Political and Commercial Determinants of Health Frameworks to Advance Public Health in the twenty-first Century.

Existing frameworks seek to elucidate the social, political, and commercial determinants of health in order to inform practice, policy, and research that can improve health and reduce health inequities. Each approach has widened the scope of public health practice and research and identified new partners and targets for intervention. But as the public health crises of the past decade have shown, these frameworks have not yet yielded insights that have enabled the public health profession and movement to prevent or overcome dominant threats to global health and health equity. This report explores the value of an integrated framework that combines insights from previous scholarship and practice using the social, political, and commercial determinants of health. It proposes the questions such an integration would need to answer and suggests processes and tasks that could lead to the creation of a blended framework.

COVID-19 risk areas associated with social vulnerability in northeastern Brazil: an ecological study in 2020.

COVID-19 is a major public health concern in this century. The causative agent SARS-CoV-2, is highly contagious and spreads continuously across territories. Spatial analysis is of enormous importance in the process of understanding the disease and its transmission mechanisms. We aimed to identify the risk areas for COVID-19 and analyze their association with social vulnerability in Maceió, Alagoas. The study was conducted in 2020. This is an ecological study to evaluate the incidence, mortality and case fatality rate of COVID-19 and their relationship with 12 indicators of human development and social vulnerability. Multivariate and spatial statistics were applied. A 95% confidence interval and a 5% confidence level were considered. The spatial scan statistic revealed the existence of six high-risk clusters for the incidence of COVID-19. The regression model showed that social indicators, such as literacy of people, residents of private households, households with more than four residents, and resident brown population, were associated with COVID-19 transmission in Maceió-AL. The disease affected localities whose populations are exposed to a context of intense socioeconomic vulnerability. Based on the results, it is necessary to adopt measures that take into account the social determinants of health in order to minimize the damage caused by the pandemic.

Factors related to the presence of suicidal ideations in adolescents after a technological disaster

BackgroundThree and a half years after a technological disaster, the train derailment in Lac-Mégantic (Quebec, Canada) in 2013, a study was conducted with adolescents to determine their mental health condition. MethodData were collected from 538 young people using a self-administered questionnaire distributed at their secondary school. One question specifically concerned the presence or absence of suicidal ideations. This article compares the characteristics of high school students who had had suicidal ideations during the 12 months preceding the survey (n = 172), with other adolescents in the same age group who had not had such ideations (n = 366). ResultsThis study revealed that close to a third of respondents (32%) said that they had had suicidal ideations during the year preceding the data collection. They differed from the other respondents due to sociodemographic, psychological, educational, familial and social factors. The characteristics related to adolescents’ mental health are mainly associated with the presence of suicidal ideations. ConclusionSuicidal ideations in adolescents are a public health concern and may appear in non-negligible numbers after a disaster. This article indicates the importance after such an event of acting on all the social determinants of health in order to protect young people at risk of developing suicidal ideations and promote their recovery.

Sampling plan and methodological aspects: a household healthcare survey in Piauí.

ABSTRACTOBJECTIVE To describe the methodological aspects of the Piauí home healthcare survey (ISAD-PI) and assess the relation between sampling plan, precision, and design effects, assuming that population health surveys are relevant instruments for health monitoring.METHODS ISAD-PI was a population-based cross-sectional study that analyzed the living conditions and health status of the population residing in urban areas in the municipalities of Teresina and Picos, in Piauí. Sampling was carried out by conglomerates in two stages: Primary Sampling Units and households. To calculate the sample size, we considered the stratification of the population in both cities, according to the age of the individuals. We evaluated the “non-response” rate (NRR) and estimated the proportions according to sex and age, as well as the prevalence of social determinants of health in order to assess the compliance of the sampling plan. Analyses related to the precision according to the coefficient of proportion variation of the standard error (Cv-pˆ) and the design effect (deff). Cv-pˆ less than 20% and deff less than 1.5 were considered adequate. The total NRR of households was 38.2% in Teresina and 38.3% in Picos. We carried out twenty-four proportion estimates in relation to age and sex and 48 prevalence of social and health determinants estimates, totaling 72 estimates. Among them, 71 had Cv-pˆ less than 20% and 61 had deff less than or equal to 1.5.CONCLUSION Data generated from the ISAD-PI may contribute to the assessment of health and morbidity conditions in the population. Furthermore, methodological aspects employed in this research may serve as a basis for studies carried out in other cities in Brazil.

Athletic Trainer-Reported Prevalence of Mental Health, Substance Use, and Barriers to Health in Secondary Schools.

Where a person lives can have a significant effect on health. Limited access to health care, food insecurity, lack of affordable housing, and violence increase a person's likelihood of poor health. Athletic trainers (ATs) can contribute to identifying and improving the determinants of health that affect student-athletes. (1) What were the current perceptions ATs had about the health behaviors (specifically mental health and substance use) of high school student-athletes? (2) What were the barriers that ATs experienced when providing health services to high school student-athletes? (3) How did the developed environment affect the health behaviors and barriers that ATs observed? Qualitative study. Online survey. Certified National Athletic Trainers' Association members employed in the secondary school setting. Demographics of ATs were collected, and the ATs' perceptions of the health of student-athletes across developed environments, prevalence of mental health issues, tobacco and substance use, barriers to health care services, and housing and food insecurities among student-athletes were surveyed. Descriptive statistics for the outcome measures were reported. A total of 7600 electronic surveys were distributed to the ATs and 911 responded (females = 62%, average age = 36 years, average experience = 12.5 years). The school setting was identified by 82.5% as public and the environment as suburban by 43.7%, rural by 30.1%, and urban by 26.1%. Participants perceived a high average prevalence of mental health concerns (32%), e-cigarette use (31.7%), and marijuana use (26.9%) among student-athletes. Significant perceived barriers to health included limited access to transportation, poverty, and housing and food insecurities. This study highlights the health disparities and barriers ATs observed when addressing the health care needs of student-athletes. Understanding the determinants of health in order to identify the causes of health disparities may better prepare ATs to manage the health needs of underserved student-athletes.

'None of my ancestors ever discussed this disease before!' How disease information shapes adaptive capacity of marginalised rural populations in India.

Smallholder farmer and tribal communities are often characterised as marginalised and highly vulnerable to emerging zoonotic diseases due to their relatively poor access to healthcare, worse-off health outcomes, proximity to sources of disease risks, and their social and livelihood organisation. Yet, access to relevant and timely disease information that could strengthen their adaptive capacity remain challenging and poorly characterised in the empirical literature. This paper addresses this gap by exploring the role of disease information in shaping the adaptive capacity of smallholder farmer and tribal groups to Kyasanur Forest Disease (KFD), a tick-borne viral haemorrhagic fever. We carried out household surveys (n = 229) and in-depth interviews (n = 25) in two affected districts–Shimoga and Wayanad–in the Western Ghats region.Our findings suggest that, despite the generally limited awareness about KFD, access to disease information improved households’ propensity to implement adaptation strategies relative to households that had no access to it. Of the variety of adaptation strategies implemented, vaccination, avoiding forest visits, wearing of protective clothing and footwear, application of dimethyl phthalate (DMP) oil and income diversification were identified by respondents as important adaptive measures during the outbreak seasons. Even so, we identified significant differences between individuals in exposure to disease information and its contribution to substantive adaptive action. Households reported several barriers to implement adaptation strategies including, lack of disease information, low efficacy of existing vaccine, distrust, religio-cultural sentiments, and livelihood concerns. We also found that informal information sharing presented a promising avenue from a health extension perspective albeit with trade-offs with potential distortion of the messages through misinformation and/or reporting bias. Altogether, our findings stress the importance of contextualising disease information and implementing interventions in a participatory way that sufficiently addresses the social determinants of health in order to bolster households’ adaptive capacity to KFD and other neglected endemic zoonoses.

The future of health professions education: Emerging trends in the United States.

The future of health professions education: Emerging trends in the United States.

Legal Determinants of Health: Regulating Abortion Care

AbstractIn The legal determinants of health: Harnessing the power of law for global health and sustainable development, Gostin et al. provide a sustained account of how law can and should be used as an instrument of health promotion. We pick up on the themes of this report with a specific focus of the importance of abortion for women’s sexual and reproductive health and the impact that particular ways of framing abortion in law can have on the lives of women and girls. In this short comment, we wish to emphasize that abortion regulations need to move beyond frameworks based on narrow understandings of harm towards more progressive agendas that take into account the social determinants of health in order to reduce barriers to care. This contribution is particularly relevant to the Commission’s criticism that those ‘[l]aws that stigmatise or discriminate against marginalized populations are especially harmful and exacerbate health disparities’.

1133: Racial/ethnic disparities in adverse neonatal outcomes at term

While racial/ethnic (R/E) disparities in preterm outcomes are established, there is a paucity of data on R/E differences in neonatal outcomes at term. We examined whether R/E disparities exist in neonatal adverse outcomes at 37 to 41 weeks. We performed a secondary analysis of an observational cohort of 115,502 pregnant women at 25 U.S. sites from 2008 to 2011. Women with singleton, non-anomalous pregnancies delivered at 37 to 41 weeks were included. Self-reported R/E was categorized as: non-Hispanic white (White), non-Hispanic black (Black), non-Hispanic Asian (Asian), or Hispanic. Women without R/E recorded or recorded as “other” were excluded. Multivariable regression was used to estimate the association between R/E and a composite of adverse neonatal outcomes (CANO) defined as any of the following: perinatal death, ventilator support, Apgar score < 4 at 5 min, hypoxic-ischemic encephalopathy, subgaleal hemorrhage, skeletal fracture, infant stay > maternal (≥3 days), brachial plexus or facial nerve palsy. Secondary outcomes were NICU stay for ≥2 days and small (SGA)- or large (LGA)- for gestational age. Of 72,117 women, 48% were White, 20% Black, 5% Asian, and 26% Hispanic. The groups differed significantly by maternal characteristics (Table 1). In the unadjusted analysis, neonates of Black women had the highest frequencies of CANO and NICU stay ≥2 days, while neonates of Hispanic women were at lowest risk; SGA and LGA were higher among neonates born to Asian and Hispanic women, respectively (Table 2). In the adjusted model – which included insurance status and BMI – the risk of CANO and NICU stay remained lowest for neonates of Hispanic women, and additionally the risk of CANO were lower for neonates of Black women (as were SGA and LGA). CANO is more frequent among term neonates of Black women compared with those of White women. After adjusting for factors such as insurance status this increased risk is no longer observed, suggesting the importance of addressing strategies that address social determinants of health in order to lessen extant health disparities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

If cultural sensitivity is not enough to reduce health disparities, what will pharmacy education do next?

IntroductionSocial determinants greatly impact health, and evidence suggests that health disparities still exist between patient populations. The pharmacist's role in public health continues to evolve; therefore, the deliberate integration of public health into pharmacy education is essential. Pharmacy graduates must be able to recognize social determinants of health in order to help reduce disparities and inequities in access to quality care. PerspectiveCultural sensitivity training has been one of the most commonly used vehicles to educate students about health disparities. Whereas cultural sensitivity is of critical importance, it could unintentionally perpetuate the idea of culture as the sole construct to predict health outcomes. Consequently, it is important that we approach this societal problem from a public health perspective by addressing not just culture, but all other social determinants of health. ImplicationsAs disparities in health outcomes continue to widen for some patient groups, it is imperative for pharmacy programs to explore novel instructional approaches to teach health disparities. A paradigm shift from awareness to action and advocacy must involve educating students on the multifaceted effects of social determinants when designing interventions to help reduce health disparities.

Social inequalities in quality of life in a cohort of women diagnosed with breast cancer in Barcelona (DAMA Cohort)

BackgroundBreast cancer is a challenge for women’s health-related quality of life (QoL), compromising their physical health and emotional well-being. QoL is equally distributed among different social groups. The aim of this study to analyze the impact of clinical characteristics and social determinants of health on the QoL of a cohort of women diagnosed and/or treated for breast cancer between 2003 and 2013 in one of the main hospitals in Barcelona’s public health network. MethodsWe performed a descriptive cross-sectional study in a cohort of 2235 women with various stages of breast cancer at different stages of their disease. Data were obtained using questionnaires QLQ-C30 and QLQ-BR23 from the European Organization for Research and Treatment of Cancer (EORTC), which include a set of functional and symptomatic scales. We conducted descriptive and bivariate analysis using the Chi-Square test and adjusted for relevant variables using logistic regression. The dependent variables were the functional scales of QoL and the independent variables were sociodemographic and clinical variables. ResultsWe observed significant differences for most QoL functions. Women from the most disadvantaged class, those in social isolation, or those who had suffered relapses showed the poorest results for most of the function scales. In contrast, age had differential effects depending on the function studied. ConclusionsThe QoL of women diagnosed with breast cancer is closely linked to both their social and economic status, and to their stage of disease progression. It is necessary to explore interventions that focus on the social determinants of health in order to mitigate their effects on breast cancer survivors’ QoL.

Development of a wellness trust to improve population health: Case-study of a United States urban center.

Across the United States health systems are recognizing the urgency of addressing the social determinants of health in order to improve population health. Wellness trusts, modeled after financial trusts support primary health prevention in community settings, provide an innovative opportunity for better community-clinical linkages, collaboration, and impact. This study aimed to understand the necessary tenets for a wellness trust in Brooklyn, New York (USA) and examined community interest and political will; administrative, financing, and leadership structures; and metrics and data sources to monitor and assess impact. We employed a multi-method design. Key informant interviews (KIIs) (n = 15) were conducted from 7/2016 to 1/2017. A content analysis of grey literature was used to analyze community interest and political will (n = 38). Extant datasets, such as New York City Community District profiles, were reviewed, and a narrative review was used to assess cost-effectiveness of prevention interventions (n = 33). The KIIs and grey literature underwent thematic analysis. Findings indicated healthcare issues dominated the health agenda despite recognition of social determinants of health. Braided funding (discrete funds that are coordinated but tracked separately) and blended funding (funds pooled from multiple sources tracked together) are common funding mechanisms. Robust data systems exist to assess impact. Indicators should address social determinants, performance and impact, be measurable, geographically specific, and include communities. Wellness trusts should be sustainable, engage communities, foster collaboration, and have adequate capacity. The Collective Impact Framework, a mechanism to coordinate and maximize efforts, offers this organizational structure. Wellness trusts are promising mechanisms to advance population health.

Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities.

Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes). Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control. Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups. Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Seeking out ‘easy targets’? Tobacco companies, health inequalities and public policy

IntroductionThe prominence of socioeconomic and ethnic disparities in tobacco use has led to increased policy attention on smoking inequalities in many countries. In 2008 the UK Department of Health held...

Health inequality and governance in Scotland since 2007

BackgroundSince Scottish devolution in 1999, successive governments have accorded priority to reducing health inequality and increasing economic growth. The Scottish Nationalist Party Government elected in 2007 and re-elected in 2011 has accorded considerable attention and allocated substantial resources to addressing these priorities. This article describes why, how and with what results to date the participants in the governance of Scotland, broadly defined to include persons outside as well as within central government, have addressed the determinants of health in order to reduce inequality and, as a result, improve the health status of the population. Study designInterpretive analysis. MethodsResearch for this article applied the methods of interpretive social science to obtain and analyse published and unpublished public documents; secondary sources in relevant disciplines; and interviews with ministers, officials, staff of National Health Service Scotland and its regions, and other persons active in health governance in Scotland. ResultsParticipants in the governance of health affairs in Scotland are making important contributions to the reduction of health inequality and the improvement of population health by: (1) linking policy to address health inequality with policy to make health care, public health, social and housing services, and education more effective and efficient; (2) linking policy to address the determinants of health with policy to stimulate economic growth and, as a result, increase employment and income; and (3) embracing and applying a unique synthesis of research findings about the causes of deficiencies in population health status that contribute to health inequality. ConclusionsThese findings could contribute to revising the assumptions and recommendations of some of the researchers and policy advisers who study the determinants of population health, and thus of health inequality, in order to recommend policy. Many contributors to the literature on population health argue that the determinants of health are universal, and that effective interventions to address them are also likely to be universal. Research for this article suggests, however, that participants in the governance of one country, and perhaps of each country, take account of its culture, history and current politics when they describe the determinants of health in order to propose policy to reduce health inequality. The Scottish experience described in this article could, therefore, contribute to conversations about health policy that involve leaders in governance from numerous jurisdictions; conversations that have been occurring regularly for two decades.

Social and environmental health determinants and their relationship with parasitic diseases in asymptomatic children from a shantytown in Buenos Aires, Argentina

Health inequities are a common problem for all countries and are the result of not only adverse social conditions but also poor public policies. Today chronic diseases represent the most relevant threats and are a current challenge. Parasitic infections, a leading cause of child morbidity affecting low-income populations, can be transmitted because of an unhealthy environment. Notwithstanding, scarce data have been published on the epidemiological profile of intestinal parasitoses in asymptomatic children living in shantytowns. Vulnerable populations settled in slums are growing in Argentina, particularly in Buenos Aires city. Consequently, this work intended to screen healthy carriers of enteric parasites and determine the epidemiologic profile in asymptomatic children residing in one of those communities, to explore risk factors associated with the transmission of parasites, and to initiate a basic health education campaign to promote healthy behavior in the community.Fecal samples (n = 138) were analyzed by conventional parasitological methods and a survey gathered data on symptoms, family composition, and environmental and hygiene-related variables. High prevalence of feco-orally-transmitted parasitoses (83·3%) and polyparasitism were remarkable findings. The main environmental health determinants were those related to excreta disposal and water provision. Health promotion actions were performed through the diffusion of a set of posters with iconic images and brief messages for health education.Results suggest the need for an environmental sanitation policy to complement health promotion actions. It is essential to spread the results of investigations that address inequities and social determinants of health in order to integrate data with local political processes and alert on acceptable actions for developing appropriate interventions.

Fair society, healthy lives

The final report of the World Health Organization Commission on the Social Determinants of Health (CSDH), published in 2008, affirmed that social injustice was killing on a grand scale, with a toxic combination of 'poor social policies and programmes, unfair economic arrangements, and bad politics' being responsible for producing and reinforcing health inequalities. It provided a comprehensive evidence-based discussion of pervasive inequalities of health in many countries, demonstrating the presence of a social gradient in health outcomes associated with the unfair distribution of the social determinants of health. The social determinants of health include the conditions in which people are born, grow, live, work and age, and the fundamental drivers of these conditions: the distribution of power; money; and resources. Following publication of the CSDH report and recommendations for action, the UK Government commissioned a Strategic Review of Health Inequalities in England. This article provides an overview and reflection on the findings from the CSDH and the Strategic Review of Health Inequalities in England, reviewing the case for putting fairness at the heart of all policy making. In the process, it highlights the need for action on the social determinants of health in order to address health inequalities and the social gradient in health outcomes.

Vulnerability of indigenous health to climate change: A case study of Uganda's Batwa Pygmies

The potential impacts of climate change on human health in sub-Saharan Africa are wide-ranging, complex, and largely adverse. The region's Indigenous peoples are considered to be at heightened risk given their relatively poor health outcomes, marginal social status, and resource-based livelihoods; however, little attention has been given to these most vulnerable of the vulnerable. This paper contributes to addressing this gap by taking a bottom-up approach to assessing health vulnerabilities to climate change in two Batwa Pygmy communities in rural Uganda. Rapid Rural Appraisal and PhotoVoice field methods complemented by qualitative data analysis were used to identify key climate-sensitive, community-identified health outcomes, describe determinants of sensitivity at multiple scales, and characterize adaptive capacity of Batwa health systems. The findings stress the importance of human drivers of vulnerability and adaptive capacity and the need to address social determinants of health in order to reduce the potential disease burden of climate change.