Wider Social Determinants Of Health Research Articles

The challenge of implementing peer-led interventions in a professionalized health service: a case study of the national health trainers service in England.

Policy Points: In 2004, England's National Health Service introduced health trainer services to help individuals adopt healthier lifestyles and to redress national health inequalities. Over time these anticipated community-focused services became more NHS-focused, delivering "downstream" lifestyle interventions. At the same time, individuals' lifestyle choices were abstracted from the wider social determinants of health and the potential to address inequalities was diminished. While different service models are needed to engage hard-to-reach populations, the long-term sustainability of any new service model depends on its aligning with the established medical system's characteristics. In 2004, the English Public Health White Paper Choosing Health introduced "health trainers" as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage "hard-to-reach" individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services. During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data. Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. The health trainer services have become more "medicalized" over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics.

Equidad en salud en la región más desigual del mundo: un reto de políticas públicas en América Latina

Re-democratization has transformed the social agenda and the role of the state in Latin America with a growing commitment to health equity and social justice, yet these aspirations are strained by the region´s profound socioeconomic inequalities. Efforts to provide universal coverage to the right to health have led to the development of a variety of public policies, whose scope depends on how the concepts of health and equity are understood. In general, policy action has centered on health system reforms and only recently on integrated intersectorial action to address wider social determinants of health, particularly structural determinants. Furthermore, if the goal is health equity the predominant minimum standards approach cannot be the final answer, but only a step on the road to equality. Finally, realizing universal coverage of the right to health through public policy requires the strengthening of governmental institutional capacities with an intersectorial and participatory lens.

What can the NHS do to prevent and reduce health inequalities?

A new set of papers from GPs at the Deep End imagines how the NHS should address the inverse care law, reduce the consequences of inequalities in health for individual patients, and narrow social differences in life expectancy.1 The principal causes of inequalities in health lie outside the health service, which is why policies to prevent health inequalities must address the wider social determinants of health, starting in childhood. However, it is insufficient to focus on the prevention of future inequalities in health. It is also necessary to reduce existing inequalities in health, and to prevent them getting wider. In practice, these approaches are complementary (Box 1). #### Box 1. Prevention and treatment in one family David is 14 months old. His 18-year-old mum Sarah has had anxiety problems since her older brother hanged himself 4 years ago. She started college but left when she became pregnant shortly afterwards. Sarah does not get on well with her mother, whom she accuses of drinking and ‘always shouting’ since her brother died. Her mum says she is ‘mental’ and a ‘teenage brat’. Sarah relies heavily on her own gran Margaret. Aged 50 years, she has moderately severe COPD (emphysema) and continues to smoke. Margaret has had several chest infections recently and is struggling to cope with Sarah’s often strange behaviour and with a lively toddler for whom she is the main care giver. For David the next 2 years, as he learns to walk, talk, and interact, will have a huge effect on the rest of his life. Early years interventions such as parenting classes may be important, but on their own will fail to change his life opportunities. He will need supportive neighbours, a good nursery, and adequate family income, but also optimal COPD nurse reviews, responsive alcohol and mental health services, good communication with social workers, persistent …

Promoting active ageing in older people from black and minority ethnic groups

Promoting active ageing among older adults from black and minority ethnic (BME) groups through the uptake and subsequent adherence of physical activity is an important public health issue. Although health promotion among older people is no longer a focus of practice for health visitors, they still have a key role as part of the multidisciplinary team by assessing levels of physical activity, identifying actual and potential barriers to increasing physical activity, facilitating equitable access to physical activity programmes and services, and enabling older adults from BME groups to achieve the recommended physical activity levels through adapting and tailoring information and advice. Additionally, health visitors can act on the wider social determinants of health that may influence behaviour change to reduce inequalities in access to physical activity, provision and referral by lobbying locally and nationally for improvements in local access to exercise and physical activity programmes, transport and creating built and natural environments that promote and support physical activity.

How will a life course framework be used to tackle wider social determinants of health?

The life course framework, proposed by Kuh and Schlomo in 1997, offers policy makers the means to understand the interaction between nature and nurture. This conceptual model illustrates how an individual's biological resources are influenced by their genetic endowment, their prenatal and postnatal development and their social and physical environment, both in early life and throughout the life course. Health is conceptualized as a dynamic process connecting biological and social elements that are affected by previous experiences and by present circumstances. Therefore, exposure at different stages of people's lives can either enhance or deplete the individual's health resources. Indeed, life course processes are of many kinds, including parent-child relationships, levels of social deprivation, the acquisition of emotional and behavioural assets in adolescence and the long-term effects of occupational hazards and work stress. The long-term effects of nature and nurture combine to influence disease outcomes. It is only in the last decade that theories, methods and new data have begun to be amalgamated, allowing us to further our understanding of health over the life course in ways that may eventually lead to more effective health policies and better health care. This article discusses life course concepts and how this framework can enlighten our understanding of wider social determinants of health, and provides a few examples of potential interventions to tackle their impact on health.

The relationship between maternal education and mortality among women giving birth in health care institutions: Analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health

BackgroundApproximately one-third of a million women die each year from pregnancy-related conditions. Three-quarters of these deaths are considered avoidable. Millennium Development Goal five calls for a reduction in maternal mortality and the establishment of universal access to high quality reproductive health care. There is evidence of a relationship between lower levels of maternal education and higher maternal mortality. This study examines the relationship between maternal education and maternal mortality among women giving birth in health care institutions and investigates the association of maternal age, marital status, parity, institutional capacity and state-level investment in health care with these relationships.MethodsCross-sectional information was collected on 287,035 inpatients giving birth in 373 health care institutions in 24 countries in Africa, Asia and Latin America, between 2004-2005 (in Africa and Latin America) and 2007-2008 (in Asia) as part of the WHO Global Survey on Maternal and Perinatal Health. Analyses investigated associations between indicators measured at the individual, institutional and country level and maternal mortality during the intrapartum period: from admission to, until discharge from, the institution where women gave birth. There were 363 maternal deaths.ResultsIn the adjusted models, women with no education had 2.7 times and those with between one and six years of education had twice the risk of maternal mortality of women with more than 12 years of education. Institutional capacity was not associated with maternal mortality in the adjusted model. Those not married or cohabiting had almost twice the risk of death of those who were. There was a significantly higher risk of death among those aged over 35 (compared with those aged between 20 and 25 years), those with higher numbers of previous births and lower levels of state investment in health care. There were also additional effects relating to country of residence which were not explained in the model.ConclusionsLower levels of maternal education were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum care. More attention should be given to the wider social determinants of health when devising strategies to reduce maternal mortality and to achieve the increasingly elusive MDG for maternal mortality.

Different Welfare States—Different Policies? An Analysis of the Substance of National Health Promotion Policies in Three European Countries

This study examines healthy public policy development in three European countries representing different welfare regimes: England representing the liberal model; Norway, the social democratic model; and the Netherlands, the corporatist model. National policy documents were used for the analysis. In England and Norway, health promotion has a prominent place and there is a political focus on the broader determinants of health. However, while the Norwegian policies have an explicit focus on the social gradient, the English policies have a much clearer focus on disadvantaged groups and geographic areas. In the Netherlands, the main focus is on disease prevention and risk behaviors. In the Netherlands and England there is a strong focus on the free will of the population in changing unhealthy lifestyles. By analyzing the different policies in the light of Esping-Andersen's typology of welfare state regimes, it is possible to better understand the differences among the countries. While all types of regimes seem willing to develop targeted measures, the social democratic regime seems the most willing to also develop structural measures addressing the wider social determinants of health.

A new direction for public health in England: few devils, few details

A quarter of a century ago, the Acheson Report 1 helped to address the challenges of a public health system perceived to be unsuitable in the wake of policy failures, concerns over communicable disease control, an imminent NHS reorganisation, a demoralised public health workforce, and uncertainty over how to meet the challenges of commissioning. Can Healthy Lives, Healthy People deal with many of the same challenges today?2 Public health professionals awaited the coalition government's public health White Paper with nervous apprehension. Their detachment from the White Paper's development was underlined by private sector involvement in shaping public health policy. Nevertheless, this government has not shelved the Marmot review ( Fair Society, Healthy Lives ) in the manner of their predecessor's response to the Black Report a generation earlier. Rather it has billed this White Paper as a response to Marmot's work and adopted its life course framework for tackling the wider social determinants of health.3 Can this government use such expertise to address health inequalities where the last government is widely perceived to have failed?4 Healthy Lives, Healthy People is a perplexing amalgam. Much of the document covers familiar ground describing health and wellbeing today and opportunities for major advances. GPs need no reminding of how unequally health-determining opportunities are distributed or how improvements to child public health and educational attainment could reduce later risks of physical and mental illness. The costs of many lost opportunities are …

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys.

BackgroundInequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.MethodsSeveral rounds (2002, 2004, 2006, and 2008) of the South African General Household Surveys (GHS) data were used, with standardized and normalized self-reported illness and disability concentration indices to assess the distribution of illness and disability across socio-economic groups. Composite indices of socio-economic status were created using a set of common assets and household characteristics.ResultsThis study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008. These results have also been confirmed internationally.ConclusionThe current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.

The experience of community engagement for individuals: a rapid review of evidence

Community engagement is central to strategies to promote health and well-being and reduce health inequalities in many countries, particularly interventions which focus on improving health in disadvantaged populations. Despite the widespread use of community engagement approaches, however, there have been relatively few attempts to review the evidence on the impact that participation has on the lives of individuals involved. Drawing on a wider review of evidence carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), this article reports on a rapid review of evidence of the effectiveness of initiatives which seek to engage communities in action to address the wider social determinants of health, to explore individuals' subjective experiences of engagement. The rapid review process was guided by NICE's public health methods manual, adapted to suit the diversity of the evidence. A total of 22 studies were identified containing empirical data on subjective experiences of community engagement for individuals. The findings of the rapid review suggest that the majority of 'engaged' individuals perceived benefits for their physical and psychological health, self-confidence, self-esteem, sense of personal empowerment and social relationships. Set against these positive outcomes, however, the evidence suggests that there are unintended negative consequences of community engagement for some individuals, which may pose a risk to well-being. These consequences included exhaustion and stress, as involvement drained participants' energy levels as well as time and financial resources. The physical demands of engagement were reported as particularly onerous by individuals with disabilities. Consultation fatigue and disappointment were negative consequences for some participants who had experienced successive waves of engagement initiatives. For some individuals, engagement may involve a process of negotiation between gains and losses. This complexity needs to be more widely recognised among those who seek to engage communities.

Improving the view of Scotland’s health: The impact of a public health observatory upon health improvement policy, action and monitoring in a devolved nation

The Scottish Public Health Observatory (ScotPHO) is a collaboration of the observatory sections/functions of several organizations. It operates within a small country, part of the UK, with devolved legislative and executive powers in health and in many areas relating to wider social determinants of health. The short-term impact of ScotPHO on health improvement action, policy and monitoring is described. A key factor in ScotPHO's impact is the directness of its contact with Scottish government policy and analysis leadership. The context and organization of ScotPHO differentiates it from other PHOs in the UK and Ireland, but many of the health and information challenges faced are similar and the Association of Public Health Observatories enables experience and expertise to be shared.

Perceptions of community participation and health gain in a community project for the South Asian population: a qualitative study

The new public health rejects old individualist attempts at improving health and embraces community-based approaches in reducing health inequalities. Primary Care Trusts in England face the challenge of converting community participation in health into reality. This study explores differences in perception of participation between lay and professional stakeholders of a community health project for a South Asian population in Greater Manchester. In-depth interviews and focus groups were used to explore the views of professional and lay stakeholders. All data were audio-taped, transcribed and analysed for emerging themes using a qualitative framework. Professionals talked of working in partnership with the community but lay stakeholders did not feel that they had control over the project. There were problems in engaging the community and local health professionals in the project. Lack of cultural awareness hampered participation in the project. There was agreement that the project improved the self-confidence of participants and created a more informed population. However, there was little support for claims of improvements in social cohesion and changes in lifestyle directly as a result of the project. Converting the rhetoric of community participation in health into reality is a greater challenge than was envisaged by policy makers. Marginalized communities may not be willing participants and issues of language and cultural sensitivity are important. Project outcomes need to be agreed to ensure projects are evaluated appropriately. Projects with South Asian communities should not be seen to be dealing with all 'ethnic health' issues without addressing changes in statutory organizations and other wider social determinants of health.