HNSC 3162 Biological Concepts in Public Health (Cai)

Learning Objectives:

By the end of this section, you will be able to:

• define health promotion.
• describe the significance of Ottawa charter and identify examples in each key component.

Content

More than 200 participants from 38 countries met in November 1986 in Ottawa to exchange experiences and share knowledge of health promotion. The conference stimulated an open dialogue among health workers. politicians, academics and representatives of governmental. voluntary and community organizations. The charter they drew up reflected their individual and collective commitment to the common goal of Health for all by the year 2000.

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Learning Objectives:

By the end of this section, you will be able to:

• describe what social determinants of health are.
• identify elements in the structural and intermediary social determinants as developed by WHO.

Content

Executive Summary

Complexity defines health. Now, more than ever, in the age of globalization, is this so. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization (WHO) to get to the heart of this complexity. They were tasked with summarizing the evidence on how the structure of societies, through myriad social interactions, norms and institutions, are affecting population health, and what governments and public health can do about it. To guide the Commission in its mammoth task, the WHO Secretariat conducted a review and summary of different frameworks for understanding the social determinants of health. This review was summarized and synthesized into a single conceptual framework for action on the social determinants of health which was proposed to and, largely, accepted by, the CSDH for orienting their work. A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result. This paper describes the review, how the proposed conceptual framework was developed, and identifies elements of policy directions for action implied by the proposed conceptual framework and analysis of policy approaches.

A key lesson from history (including results from the previous “historical” paper - see Discussion Paper 1 in this Series), is that international health agendas have tended to oscillate between: a focus on technology-based medical care and public health interventions, and an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action. In this context, the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutional commitments to health equity and social justice.

Having health framed as a social phenomenon emphasizes health as a topic of social justice more broadly. Consequently, health equity (described by the absence of unfair and avoidable or remediable differences in health among social groups) becomes a guiding criterion or principle. Moreover, the framing of social justice and health equity, points towards the adoption of related human rights frameworks as vehicles for enabling the realization of health equity, wherein the state is the primary responsible duty bearer. In spite of human rights having been interpreted in individualistic terms in some intellectual and legal traditions, notably the Anglo-Saxon, the frameworks and instruments associated with human rights guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having been associated with historical struggles for solidarity and the empowerment of the deprived they form a powerful operational framework for articulating the principle of health equity.

Theories on the social production of health and disease

With this general framing in mind, developing a conceptual framework on social determinants of health (SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three main theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social frameworks.

All three of these theoretical traditions, use the following main pathways and mechanisms to explain causation: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives. Each of these theories and associated pathways and mechanisms strongly emphasize the concept of “social position”, which is found to play a central role in the social determinants of health inequities.

A very persuasive account of how differences in social position account for health inequities is found in the Diderichsen’s model of “the mechanisms of health inequality”. Didierichsen’s work identifies how the following mechanisms stratify health outcomes:

• Social contexts, which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions.
• Social stratification in turn engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability.
• Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes per se).

The role of social position in generating health inequities necessitates a central role for a further two conceptual clarifications. First, the central role of power. While classical conceptualizations of power equate power with domination, these can also be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action as embodied in legal system class suits. In this context, human rights embody a demand on the part of oppressed and marginalized communities for the expression of their collective social power. The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. Second, it is important to clarify the conceptual and practical distinction between the social causes of health and the social factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework makes a point of making clear this distinction.

On this second point of clarification, conflating the social determinants of health and the social processes that shape these determinants’ unequal distribution can seriously mislead policy. Over recent decades, social and economic policies that have been associated with positive aggregate trends in health determining social factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups. Furthermore, policy objectives are defined quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities.

The CSDH Conceptual Framework

Bringing these various elements together, the CSDH framework, summarized in Figure A, shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. Illness can “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions.

“Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market; the educational system, political institutions and other cultural and societal values. Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies). In the CSDH framework, structural mechanisms are those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and processes of the socioeconomic and political context.

The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity.

Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors. The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant.

• Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment.
• Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof).
• Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.

The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people’s lives.

Policy action

Finally, in turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified. These may be based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population. A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other.

Policy development frameworks can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. The review showed the framework that Diderichsen and colleagues proposed- a typology or mapping of entry points for policy action on SDH inequities - to be very useful in the way it is very closely aligned to theories of causation. They identify actions related to: social stratification; differential exposure/ differential vulnerability; differential consequences and macro social conditions.

Considerations of these policy action frameworks lead to discussion of three key strategic directions for policy work to tackle the SDH, with a particular emphasis on tackling health inequities: (1) the need for strategies to address context; (2) intersectoral action; and (3) social participation and empowerment.

Policy action challenges for the CSDH

Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups (see Figure B). To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches. 8

A key task for the CSDH will be:

1. to identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and to characterize in detail the political and management mechanisms that have enabled effective intersectoral programmes to function sustainably.
2. to demonstrate how participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward after the Commission has completed its work.
3. Finally, SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science.

Knowledge Check:

Go to Next Selected Concepts of Public Health:

Learning Objectives:

By the end of this section, you will be able to:

• define health literacy.
• describe why health literacy matter

Content:

What is Health Literacy?

In the report, Healthy People , the U.S. Department of Health and Human Services included improved consumer health literacy and identified health literacy as an important component of health communication, medical product safety, and oral health. Health literacy is defined in Healthy People as: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor’s directions and consent forms, and the ability to negotiate complex health care systems. Health literacy is not simply the ability to read. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations.

Health literacy varies by context and setting and is not necessarily related to years of education or general reading ability. A person who functions adequately at home or work may have marginal or inadequate literacy in a health care environment. With the move towards a more “consumer-centric” health care system as part of an overall effort to improve the quality of health care and to reduce health care costs, individuals need to take an even more active role in health care related decisions. To accomplish this people need strong health information skills.

Why Does Health Literacy Matter?

Every day, people confront situations that involve life-changing decisions about their health. These decisions are made in places such as grocery and drug stores, workplaces, playgrounds, doctors’ offices, clinics and hospitals, and around the kitchen table. Obtaining, communicating, processing, and understanding health information and services are essential steps in making appropriate health decisions; however, research indicates that today’s health information is presented in ways that are not usable by most adults. “Limited health literacy” occurs when people can’t find and use the health information and services they need.

• Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media, and communities.
• Without clear information and an understanding of the information’s importance, people are more likely to skip necessary medical tests, end up in the emergency room more often, and have a harder time managing chronic diseases like diabetes or high blood pressure.

Whom Does Health Literacy Affect?

People of all ages, races, incomes, and educational levels can find it difficult to obtain, communicate, process, and understand health information and services. Literacy skills are only a part of health literacy. Even people with strong reading and writing skills can face health literacy challenges when they are not familiar with medical terms or how their bodies work. They have to interpret or calculate numbers or risks that could have immediate effects on their health and safety. They are diagnosed with a serious illness and are scared or confused. They have health conditions that require complicated self-care. Every organization involved in health information and services needs its own health literacy plan to improve its organizational practices to help everyone of all ages.

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