Social Determinants Of Health Approach Research Articles

Advancing Equity in U.S. Hospital Systems: Employee Understandings of Health Equity and Steps for Improvement.

Equity in the U.S. healthcare system remains a vital goal for healthcare leaders. Although many hospitals and healthcare systems have adopted a social determinants of health approach to more equitable care, many challenges have limited the effectiveness of their efforts. In this study, we wanted to explore whether healthcare leaders and providers understand the concept of equity and can link the concepts to practical applications within healthcare systems. We explored how hospital leadership and providers at a major public hospital in Atlanta, Georgia, understand equity topics both conceptually and at a practical implementation level. We conducted 28 focus groups for >4 months involving 233 staff members, during which participants were asked about their understanding of various equity-related terms and equity implementation within the hospital. Our findings reveal that there is little consensus among staff regarding the conceptual meanings of various health equity-related terms, and only a small minority of staff can articulate a conceptual definition that reflects current research-based understandings of equity. Furthermore, there is little consensus regarding how staff believes that health equity is practically enacted through various hospital programs, even among interviewees who could correctly articulate equity topics. These findings have no association with a role in the organization or length of time employed at the hospital. These findings indicate a need for a more nuanced understanding of health equity and further clarification and education on how to implement health equity. Although understanding at the conceptual level is an important first step, conceptual knowledge alone is not enough to support health equity at either the individual staff level or the system level. Our recommendations cover strategic development; education specific to the hospital system and its unique needs; consideration of the specific roles of individuals in the organization; and the designation of diversity, equity, and inclusion staff and offices in a hospital organization.

Social Determinants of Health in Rural and Urban Communities

The purpose of this study is to better understand the social factors that influence the health of community members. Both a descriptive and a narrative study design were used to create this article. The social determinants of health (SDH), which are non-medical factors that can be changed by social policies and have a major impact on health, have attracted the attention of the public health community during the past two decades. SDH are non-medical factors that can be changed by social policies and substantially impact health. It is clear that there is widespread support for an SDH approach around the world, ranging from national action to global political commitment. The purpose of this study is to explore the social factors that influence the health of community members. However, differences in the conditions in which people are born, raised, employed, and aged result from differences in power, wealth, and resources. Political, economic, and resource allocation decisions made outside the health sector must consider health as a result throughout the social distribution in order to prevent a concentration primarily on increasing production. Health can be considered in any plan, which can help to some extent to ensure that it is considered. By tracking the development of SDH on a global basis and concentrating on how successful policies and implementation plans may be enhanced going forward, standard procedures will be discovered and exchanged. The WHO's attempts to align measures with the SDGs will boost the assessment of progress.

Considerations for an urban health perspective in Chile from the "Quiero Mi Barrio" program.

To explore the perceptions of residents regarding their health and well-being in areas of personal and collective life, in relation to the experience of urban transformation originated by the Program for the Recovery of Neighborhoods in Chile "Quiero mi Barrio" (PQMB). Qualitative study conducted in eight neighborhoods, which were subject to interventions between 2012-2015, located in seven communes of Chile: Arica, Renca, Padre Las Casas, Villarrica, Castro, Ancud. Eighteen focus groups and 27 interviews were conducted between 2018 and 2019. A content analysis was carried out following the social determinants of health approach. Material conditions of neighborhood infrastructure and psychosocial determinants were the main emerging and predominant categories in the residents' narratives. The new or improved infrastructure enhances sports and playing practices, as well as contributes to the feeling of safety and to the improvement of walkable spaces, support networks, socialization and dynamization of social organization. However, neglected aspects were visualized. The program had limitations of structural character that operate locally, such as aging, individual lifestyles that limit participation, and contexts of insecurity, especially in neighborhoods victims of drug trafficking. The urban changes originated by the PQMB included improvements in neighborhood infrastructure and in the psychosocial environment, which are perceived by residents as beneficial aspects and promoters of collective wellbeing. However, global phenomena, and those related to the program, limit its scope and have repercussions on the perception of overall wellbeing of the residents in the neighborhoods. To go deeper into how this or other state neighborhood programs may or may not favor equitable access of different social groups, or which works may be better used by the groups, is an aspect that enhances the integral action with other sectors and local actors in the territories.

Spatial patterns in sociodemographic factors explain to a large extent the prevalence of hypertension and diabetes in Aragon (Spain).

The global burden of multi-morbidity has become a major public health challenge due to the multi stakeholder action required to its prevention and control. The Social Determinants of Health approach is the basis for the establishment of health as a cross-cutting element of public policies toward enhanced and more efficient decision making for prevention and management. To identify spatially varying relationships between the multi-morbidity of hypertension and diabetes and the sociodemographic settings (2015-2019) in Aragon (a mediterranean region of Northeastern Spain) from an ecological perspective. First, we compiled data on the prevalence of hypertension, diabetes, and sociodemographic variables to build a spatial geodatabase. Then, a Principal Component Analysis (PCA) was performed to derive regression variables, i.e., aggregating prevalence rates into a multi-morbidity component (stratified by sex) and sociodemographic covariate into a reduced but meaningful number of factors. Finally, we applied Geographically Weighted Regression (GWR) and cartographic design techniques to investigate the spatial variability of the relationships between multi-morbidity and sociodemographic variables. The GWR models revealed spatial explicit relationships with large heterogeneity. The sociodemographic environment participates in the explanation of the spatial behavior of multi-morbidity, reaching maximum local explained variance (R2) of 0.76 in men and 0.91 in women. The spatial gradient in the strength of the observed relationships was sharper in models addressing men's prevalence, while women's models attained more consistent and higher explanatory performance. Modeling the prevalence of chronic diseases using GWR enables to identify specific areas in which the sociodemographic environment is explicitly manifested as a driving factor of multi-morbidity. This is step forward in supporting decision making as it highlights multi-scale contexts of vulnerability, hence allowing specific action suitable to the setting to be taken.

Access to health services for chronic disease care during the COVID-19 pandemic in Ecuador: A qualitative analysis using a Social Determinants of Health approach

ABSTRACT This qualitative study aims to explore how the COVID-19 pandemic impacted healthcare access for patients with chronic conditions in Ecuador from the patient’s perspective. We interviewed 19 patients diagnosed with arterial hypertension or type 2 diabetes in rural and urban areas of Ecuador during August and September 2020. We used the Framework Method to analyse the interview transcripts with ATLAS.Ti 8.4 and organised the ideas discussed using categories from the World Health Organization Commission on the Social Determinants of Health conceptual framework. Reorganization of health services during the pandemic meant that patients with arterial hypertension or diabetes could no longer attend face-to-face appointments for disease follow-up. System failures related to medication supply led to increased out-of-pocket payments, which, together with reduced or absent earnings, and in a context with limited social protection policies, meant that patients frequently went for prolonged periods without medication. Rural health initiatives, support from family and use of traditional medicine were reported as ways to manage their chronic condition during this time. Barriers to disease management disproportionately affected individuals with low socioeconomic positions. Stock shortages, lack of protective labour policies and limited reach of anticipatory policies for health emergencies likely worsened pre-existing health inequities in Ecuador.

Where is the pain? A qualitative analysis of Ghana's opioid (tramadol) 'crisis' and youth perspectives.

Over the last five years, media reports in West African countries have suggested a tramadol abuse 'crisis' characterised by a precipitous rise in use by youth in the region. This discourse is connected to evidence of an emerging global opioid crisis. While the reported increase in tramadol abuse in West Africa is likely true, few studies have critically interrogated structural explanations for tramadol use by youth. Nascent academic literature has sought to explain the rise in drug use as a function of moral weakness among youth. This Ghanaian case study draws on primary and secondary data sources to explore the pain that precedes tramadol abuse. Through a discourse analysis of 295 media articles and 15 interviews (11 with youth who currently use tramadol and 4 with health system stakeholders), this study draws on structural violence and moral panic theories to contribute to the emerging literature on tramadol (ab)use in West Africa. The evidence parsed from multiple sources reveals that government responses to tramadol abuse among Ghanaian youth have focused on arrests and victim blaming often informed by a moralising discourse. Interviews with those who use tramadol on their lived experiences reveal however that although some youth use the opioid for pleasure, many use tramadol for reasons related to work and feelings of dislocation. A more complex way to understand tramadol use among young people in Ghana is to explore the pain that leads to consumption. Two kinds of pain; physical (related to strenuous work) and non-physical (related to anxiety and the condition of youth itself) explain tramadol use requiring a harm reduction and social determinants of health approach rather than the moralising 'war on drugs' approach that has been favoured by policy makers.

To what extent do Australian child and youth health, and education wellbeing policies, address the social determinants of health and health equity?: a policy analysis study

BackgroundChildren and youth are an important population group requiring specific policies to address their needs. In Australia, most children and youth are doing well, however, certain equity groups are not. To address child and youth health equity in policy, applying a social determinants of health approach is considered best practice. For over 10 years governments in Australia have been called upon to address the social determinants of health, however, there has been limited action. Health and education departments are typically most involved in policy development for children and youth. To date, there have been limited systematic analyses of Australian child and youth health policies, and selected education wellbeing policies, with a social determinants of health and health equity focus and this study aims to contribute to addressing this gap.MethodsPolicy analysis was conducted across 26 Australian child and youth health policies, and selected education wellbeing policies. We used an existing prior coding framework to understand the extent the social determinants of health and health equity were addressed. All policies were strategic level and only included if dated 2009 onwards.ResultsAcross 26 selected policies only 10% of strategies addressed the social determinants of health, demonstrating a lack of policy action. However, there is relatively even focus on all developmental stages, and an increased focus on youth. Equity is acknowledged across most policies with some groups receiving more attention including Aboriginal and Torres Strait Islander children. The social determinants of health addressed, to some degree, include early childhood development, education, parental workplace conditions, healthy settings, and housing, those least mentioned include public transport and regulation.ConclusionThis study demonstrates a lack of policy action on the social determinants of health within Australian child and youth health policy, and selected education wellbeing policies. Rather, the application of a siloed, and predominantly acute care approach. However, there is recognition of equity across all policies; an emphasis on housing as a determinant of health; and a link between health and education departments through education wellbeing policies, specifically addressing the issue of mental health.

Coping during the COVID-19 pandemic: A mixed methods approach to understand how social factors influence coping ability

The COVID-19 pandemic and public health protection measures aimed at mitigating the transmission of the virus have both resulted in tremendous physical and mental health impacts. The study at hand used a gender-based analysis and social determinants of health approach to investigate which communities had trouble coping during times of strict protection measures and symptoms and strategies employed during the COVID-19 pandemic.Participants were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Being a young adult, female, woman, gender diverse, low-income earner or LGBTQ/2S+ was significantly associated with not being able to cope during the first wave of the pandemic. The effects for females, women, and gender diverse were attenuated yet still significant when controlling for various covariates. Those who reported not coping were more likely to present maladaptive coping symptoms and strategies. Our findings demonstrate the need to support marginalized communities in coping with the current ongoing COVID-19 pandemic and build proactive support for future pandemics.

Educational level, gender and health practices regarding COVID-19 in N'Djamena, Chad: A cross-sectional study.

COVID-19 is affecting different countries and populations unequally. In this sense, sub-Saharan countries represent a particularly vulnerable context due to their unique demographic and health circumstances. A holistic approach to Covid-19 is urged, one that considers the social-cultural contexts of people’s lives. Using Social Determinants of Health (SDH) as framework, we explore which variables could explain the differences in health practices regarding the prevention of COVID-19 in Chad, in order to propose recommendations that allow communities to better face future health crises. The study was designed as a cross-sectional survey conducted in N’Djamena, Chad, using a convenience sampling technique that included 2,330 participants. A regression model was fitted to assess the relationship between educational level, gender, and health practices regarding COVID-19. 2,269 participants completed the survey successfully. Participants mean age was 31.04, 61.52% were male, and 40.55% had precarious jobs. 21.38% of participants answered right all questions regarding knowledge and 37.19% followed all preventive measures. Findings show that safe practices regarding COVID-19 depend on right knowledge. Gender influences knowledge mainly through its influence on education. Vulnerability is given by women’s reduced access to education. The SDH approach provide with an exploratory explanation and some recommendations aimed at local authorities. Access to education for all men and women must be improved to increase health practices and better deal with future health crises.

A life course view on depression: Social determinants of depressive symptom trajectories over 25 Years of Americans’ Changing Lives

ObjectivesThis study investigates heterogeneity in trajectories of depressive symptomatology in a national sample of American adults followed over 25 years. Using an innovative combination of data and methods, we sought to illuminate how depressive symptoms change over adulthood in terms of their levels and severity across 25 years, and how the social determinants of health influence differences in those trajectory paths. MethodsData come from the Americans’ Changing Lives (ACL) study, a national sample of 3617 adults (age 25+) followed over 25 years (1986–2011). Depressive symptoms were assessed with an 11-item abbreviated version of the Center for Epidemiologic Studies-Depression scale (CESD). A second-order growth mixture model was used to assess measurement invariance (addressing questions of different or changing meaning of depression) and latent trajectories of change (addressing questions of changing severity levels with aging) in depressive symptomatology over adulthood. ResultsResults indicate that the CESD was invariant across time, and depressive symptomatology followed a U-shaped form across the life course. Two latent trajectories of depressive symptoms were identified across the life course; one was a normative trajectory (60% of the sample) and the other (40% of the sample) had persistently high depressive symptoms over adulthood. Women, race/ethnic minorities, and those of lower socioeconomic position were more likely to be in the persistently depressed class. DiscussionResults are consistent with those of other studies demonstrating a U-shaped form of depressive symptoms across the life course. However, a substantial sub-population with persistent depressive symptomatology over adulthood was also identified, whose predictors suggest the need to take a social determinants of health approach to disparities related to serious and persistent mental illness.

Women's Health: Population Patterns and Social Determinants.

Women's health, and what we know about it, are influenced by social factors. From the exclusion of women's bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. After a brief history of research on women's health, we review selected patterns, trends, and inequalities in US women's health. These patterns reveal US women's poor and declining longevity relative to those in other high-income countries, gaps in knowledge about painful and debilitating conditions that affect millions of women, and deep inequalities that underscore the need to redress political and structural features of US society that enhance health for some and diminish it for others. We close by describing the challenges and opportunities for future research, and the promise of a social determinants of health approach for advancing a multilevel, intersectional, and biosocial understanding of women's health.

Social Determinants of Health as a Lens for Understanding Local News Reporting

ABSTRACT While scholars have long examined media bias, few studies have systematically examined how media represents health within American urban neighborhoods. Drawing on a qualitative analysis of 10 years of news articles of one Ohio neighborhood, the authors apply a social determinants of health (SDOH) lens to the coverage of one urban newspaper. The study’s aim is to understand what a SDOH approach might tell us about local and ongoing coverage of historically challenged neighborhoods. Findings reinforce those of previous studies from health communication and media studies which document a disproportionate emphasis on crime, but also push the conversation further to show how the health aspects of housing and food instability, unemployment, and non-crime safety concerns, are often elided in news coverage. The authors argue that the SDOH lens affords journalists a framework for ensuring that their reporting adequately captures the drivers of poor health in American urban neighborhoods.

A Role for Design in Global Health: Making the Concept of Vulnerability Actionable

The social determinants of health approach focuses on factors—apart from biomedical care—that have linked poor health outcomes to questions of socio-economic inequality and social injustice. Social determinants of health are complex and can be difficult to measure; thus, more work needs to be done to support the actionable application of the social determinants of health into global health programming. One possible application is the Pathways vulnerability approach. The Pathways approach consists of a vulnerability framework, population-representative household segmentation solutions, and a set of qualitative stories and insights that bring the framework and the segmentation to life. The goal of this approach is to enable health system actors to stratify their users according to the social, environmental, and cultural vulnerabilities associated with poor health outcomes across a range of reproductive, maternal, newborn child health, nutrition, and women’s health and well-being outcomes. In this viewpoint article, we reflect on the role that we played using design methods to bring a more woman-centered approach to understanding how women are made vulnerable by the social and cultural systems in which they are embedded and the differentiated effect this has on specific health outcomes.

The role of social determinants on unhealthy eating habits in an urban area in Mexico: A qualitative study in low-income mothers with a young child at home

Overweight and obesity are a severe public health problem in Mexico. National policies to fight unhealthy eating have been implemented but they don't target social and family environment determinants. Our study aimed to gain a deeper understanding of the determinants of unhealthy eating by exploring the perspectives and experiences of low-income Mexican women with a young child at home. We conducted a purposeful sampling to include participating kindergartens in Morelos, México. Women with a child enrolled in the kindergarten were invited to focus group discussions. Afterward, women with specific profiles were invited to in-depth interviews. During analysis we applied Dahlgren and Whitehead's model of social determinants of health (SDH). Overall, we found that participants have unhealthy habits, for example: low variability in consumption patterns, regular sugar-sweetened beverages intake and insufficient fruit and vegetable intake. By low variability we mean frequently consumed products (on most days of the week) limited to a restricted food set. As for the determinants of unhealthy habits, we found at the community level that families encourage unhealthy eating. At the household and work level, tight schedules for food preparation determine unhealthy eating. And, at a socio-economic level, lack of access and money constraints shape unhealthy habits. Unhealthy habits are determined by factors on multiple levels and using an SDH approach can be an effective way to inform comprehensive strategies targeting the overweight and obesity epidemic in Mexico and other low- and middle-income countries.

The influence of multidimensional deprivation on problem drinking developmental trajectory among young adults: a longitudinal study using latent class growth analysis

BackgroundMany young people in Korea today experience deprivation in various areas of life. The social determinants of health approach maintains that social factors play an important role in an individual’s physical and mental health. This study aimed to investigate the problem drinking trajectory of young Korean people and identify the effects of multidimensional deprivation on problem drinking.MethodsThe study used data from 2012 to 2018 found in the Korea Welfare Panel Study. Latent class growth analysis was performed to determine the number of trajectories of problem drinking. After identifying latent classes, a multinomial logistic regression analysis was utilized to examine multidimensional deprivation as a predictor of class membership.ResultsLatent class analysis yielded three groups: (1) a low-level maintenance group (low level of alcohol use maintained at the low level), (2) a moderate-level increasing group (moderate level of problem drinking with a moderate increase in problem drinking), and (3) a risky drinking increasing group (high level of problem drinking with a rapid increase in problem drinking). Results from multinomial logistic regression showed that deprivation in housing and social deprivation increased the probability of belonging to the risky drinking increasing group compared to other reference groups.ConclusionThe study speaks to the need to establish appropriate intervention strategies according to the level and changes in the pattern of alcohol use. The implications of housing and social deprivation concerning problem drinking among young Korean people are also discussed.

Social inequality and health: Food (in)security management in primary health care in Spain

Equity is an unresolved issue on the Spanish healthcare agenda. This paper explores the importance that health professionals give to social determinants of health and the means they possess to address them. It also analyzes the relationship between food insecurity and increases in certain diseases. One of its objectives is to ascertain how increasing uncertainty is being addressed in primary healthcare services. We present a qualitative study carried out in six primary care centers in the cities of Reus and Tarragona between 2018 and 2019, involving 19 practitioners active in the areas of nursing, family practice, and social work. Results indicate that the lack of resources in primary care centers makes it difficult to integrate a social determinants of health approach, and thus to mitigate inequalities. Furthermore, a lack of structural actions diminishes the ability to respond to citizens' healthcare needs.

Social Determinants Screening with Social History: Pediatrician and Resident Perspectives from a Middle-Income Country.

Social history (SH) makes it possible to learn the social environment of children in pediatric practice and enables interventions into social risks such as poverty. While SH has been evolving in use as an advocacy practice in high-income countries, that seems not to be the case in low- and middle-income countries. We explored pediatricians' and pediatric residents' opinions and experiences of SH with an aim to promote advocacy-based SH practices in Turkey. A qualitative study conducted involving interviews with pediatrics residents, pediatricians and educators, and a focus group with residents. Interviews and the focus group were transcribed and reviewed for themes using qualitative content analysis. The principal objective of SH wasfound to be diagnosis rather than advocacy. Although all participants expressed opinions about socioeconomic conditions' vital influence on child health, most reported limited use of SH. When asked about social needs screening with SH, most participants opposed with various reasons, primarily time concerns and doubts about the necessity for each child. Lack of time was reported as the leading barrier to SH by participants. Other barriers were identified as lack of structured SH education, problems regarding referrals and interdisciplinary work, and the biomedical health approach which defines the physician's role within the physical health domain. To achieve an advocacy-based SH practice, the biomedical health approach should be questioned. Action is needed to implement a social determinants of health approach and equity focus to health policies and to medical and residency education.

Exploring the local policy context for reducing health inequalities in children and young people: an in depth qualitative case study of one local authority in the North of England, UK

BackgroundImproving children and young people’s (CYP) health and addressing health inequalities are international priorities. Reducing inequalities is particularly pertinent in light of the Covid-19 outbreak which has exacerbated already widening inequalities in health. This study aimed to explore understandings of inequality, the anticipated pathways for reducing inequalities among CYP and key factors affecting the development and implementation of policy to reduce inequalities among CYP at a local level.MethodsWe carried out a qualitative case study of one local government region in the North of England (UK), comprising semi structured interviews (n = 16) with service providers with a responsibility for child health, non-participant observations of key meetings (n = 6 with 43 participants) where decisions around child health are made, and a local policy documentation review (n = 11). We employed a novel theoretical framework, drawing together different approaches to understanding policy, to guide our design and analysis.ResultsParticipants in our study understood inequalities in CYP health almost exclusively as socioeconomically patterned inequalities in health practices and outcomes. Strategies which participants perceived to reduce inequalities included: preventive support and early intervention, an early years/whole family focus, targeted working in local areas of high deprivation, organisational integration and whole system/place-based approaches. Despite demonstrating a commitment to a social determinants of health approach, efforts to reduce inequalities were described as thwarted by the prevalence of poverty and budget cuts which hindered the ability of local organisations to work together. Participants critiqued national policy which aimed to reduce inequalities in CYP health for failing to recognise local economic disparities and the interrelated nature of the determinants of health.ConclusionsDespite increased calls for a ‘whole systems’ approach to reducing inequalities in health, significant barriers to implementation remain. National governments need to work towards more joined up policy making, which takes into consideration regional disparities, allows for flexibility in interpretation and addresses the different and interrelated social determinants of health. Our findings have particular significance in light of Covid-19 and indicate the need for systems level policy responses and a health in all policies approach.

Health equity in Iran: A systematic review.

Background: Health inequities are among debatable and challenging aspects of health systems. Achieving equity through social determinants of health approach has been mentioned in most upstream national plans and acts in Iran. This paper reports the findings of a systematic review of the current synthesized evidence on health equity in Iran. Methods: This is a narrative systematic review. The relevant concepts and terminology in health equity was found through MeSH. We retrieved the relevant studies from PubMed/MedLine, Social Sciences Database, and Google Scholar in English, plus the Jihad University Database (SID), and Google Scholar in Farsi databases from 1979 until the end of January 2018. The retrieved evidence has been assessed primarily based on PICOS criteria and then Ottawa-Newcastle Scale, and CASP for qualitative studies. We used PRISMA flow diagram and a narrative approach for synthesizing the evidence. Results: We retrieved 172 455 studies. Following the primary and quality appraisal process, 114 studies were entered in the final phase of the analysis. The main part (approximately 95%) of the final phase included cross-sectional studies that had been analyzed through current descriptive inequality analysis indicators, analytical regression, or decomposition-based approaches. The studies were categorized within 3 main groups: health outcomes (40.3%), health utilization (32%), and health expenditures (27%). Conclusion: As a part of understanding the current situation of health equity in the policymakers’ need to refer the retrieved evidence in this study, they need more inputs specially regarding the social determinants of health approach. It seems that health equity research plan in Iran needs to be redirected in new paths that give appropriate weights to biological, gene-based, environmental and contextbased, economic, social, and political aspects of health as well. We advocate addressing the aspects of Social Determinant of Health (SDH) in analyzing health inequalities.

Policy actors' perceptions on applying a SDH approach in child health policy in Australia: A cross‐disciplinary approach (public health and political science)

AbstractResearch suggests policy action on the social determinants of health (SDH) is required to reduce child health inequities (HE). However, there has been limited action in this area in Australia. Political will has been identified as a barrier but few public health scholars have conducted research which adopts a political science perspective to explore this issue. This study aims to address this gap in the literature. We conducted 27 semi‐structured interviews with policy actors involved in the development of four Australian child/youth health policies selected as relatively good practice in addressing the SDH and HE. Several political science theories guided the design of the study with the Shiffman and Smith framework predominantly used, and adapted, for analysis. The findings suggest policy development was supported by a cohesive policy network, including credible leaders. Framing of issues varied with early childhood development, health equity, and child rights being clear motivators for change. Policy actors used several tactics to navigate a neoliberal policy environment and promote a SDH agenda including adopting a credible framework; consultation with children/youth; establishing an institute outside of government; engaging medical entrepreneurs; and combining a Public Health and Wellbeing Act with a healthy cities approach.