Provide a brief synopsis the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
Provide a brief synopsis the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
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Provide a brief synopsis the article. Then state why it relates to Patient Equity: Social Determinants to Improve Patient Care
Transcribed Image Text:EDITORIAL
Social
Determinants
of Health Equity
Mc Ginis et al (2002)
Supplement 4, 2014, Vol 104, No. S4| American Journal of Public Health
Health care
(up to 15%
Health behaviour
patterns (40)
Social circumstances
and environmental
exposure 145M
Language is important. The call
for papers in this supplement
was entitled health equity. Yet
the call asked for papers that
address disparities in health. In
the United States, disparities,
most often, has been used to
refer to racial/ethnic differ-
ences in health, or more com-
monly health care. We note that
the call in this supplement ex-
pands the focus and highlights
differences by socioeconomic
status and geographic location,
among others. By tradition, in
the United Kingdom we have
used the term inequalities to
describe the differences in
health between groups defined
on the basis of socioeconomic
conditions.
To reduce health inequalities
requires action to reduce socio-
economic and other inequalities.
There are other factors that in-
fluence health, but these are out-
weighed by the overwhelming
impact of social and economic
factors-the material, social, polit-
ical, and cultural conditions that
shape our lives and our behaviors.
Much of the evidence describing
this was set out in the World
Health Organization Global Com-
mission on the Social Determi-
nants of Health.¹
In fact, so close is the link
between social conditions and
health, that the magnitude of
health inequalities is an indicator
of the impact of social and eco-
nomic inequalities on people's
lives. Health then becomes an
important further cause for con-
cern about the rapid increase in
inequalities of wealth and income
in our societies. Increasingly, we
are using the language of health
reasonably equitable, universal
access to health care in England.
The six priority areas were:
quality of experiences in the early
years, education and building
personal and community resilience,
Canadian Institute of Advanced Research (2012)
Health care
(up to 25%)
Environmental
(10%)
Genetics
(15%)
Socio economic
(508)
inequity to describe those health
inequalities that, though avoid-
able, are not avoided and hence
are unfair.
EDITORIAL
Two particular issues stand in
the way before we can act on
knowledge of social determinants
of health to address health equities:
lifestyle drift and overconcentra-
tion on health care.² Lifestyle drift
describes the tendency in public
health to focus on individual be-
haviors, such as smoking, diet,
alcohol, and drugs, that are un-
doubted causes of health ineq-
uities, but to ignore the drivers of
these behaviors-the causes of the
causes.
Too often health is equated
only with health care. Lack of
access to health care has domi-
nated the debate in the United
States because of egregious ineq-
uities in access, despite spending
far more on health care than any
other country. A recent study by
the Commonwealth Fund found
that compared with other coun-
tries the US health system per-
formed relatively poorly in terms
of cost, equity, and efficiency.³
The Veterans Health Adminis-
tration, however, does have a
strong focus on equity. The
Office of Health Equity ensures
that the health care provision for
veterans provides equitable care
appropriate for the individual's
circumstance and irrespective of
geography, gender, race/ethnicity,
age, culture, or sexual orientation.
There is importance, too, in in-
corporating socioeconomic factors
into provision of equitable access
and care. The Office of Health
Equity also brings an equity focus
into organizational discussions of
policy, decision-making, resource
good quality employment and
working conditions, having suffi-
cient income to lead a healthy life,
healthy environments, and priority
public health conditions-taking
a social determinants approach
Source. Reprinted with permission from the King's Fund.
FIGURE 1-Estimates of the contribution of the main drivers of health status.
Bunker et al (1995)
Health care
(43%)
factors (57%)
to tackling smoking, alcohol, and
obesity.
At the heart of our approach is
the finding that health inequalities
are not limited to poor health for
the worst off, or the most socially
allocation, practice, and perfor
mance plans throughout the Vet-
erans Health Administration-a
health equity in all policies
approach that could be extended
to other relevant organizations
and stakeholders.
Universal access to high quality
care and a focus on equitable
outcomes, then, is central to chal-
lenging health inequities. So too is
challenging inequities in social
conditions which lead to health
inequalities. Attempts have been
made to apportion determinants.
of health status of populations-
see Figure 1, showing the rela-
tively significant proportion of
inequity attributed to social de-
terminants.
The Robert Wood Johnson
Foundation in the United States
also sets out how social factors
have as much, or even more
impact on health as the medical
care system, and it urges leaders
across the United States to shift
funding priorities to emphasize 3
areas essential to improving the
nation's health: Increasing access
to early childhood development
programs; revitalizing low-income
neighborhoods; and broaden-
ing the mission of health care
providers beyond medical
treatment. Important goals,
too, for the Veterans Health
Administration.
In our English review of health
inequalities, in 2010, we enlisted
the help of 80 or so experts and
set out a large evidence base,
which demonstrated the most im-
portant influences on health and
health inequalities. We made
recommendations in six priority
areas. None was in health care
because there is evidence of
Editorial | S517
disadvantaged. There is a striking
social gradient in health and dis-
ease running from top to bottom
of society. The social gradient
has now been shown to be wide-
spread across the world in coun-
tries at low, middle, and high
income. Figure 2 shows this gra-
dient in England for life expec-
tancy and healthy life expectancy.
There has been considerable
progress in the recognition and
adoption of the social determi-
nants of health approach to health
equity. Internationally, organiza-
tions such as the United Nations
have expressed their broad com-
mitment to health equity through
action on the social determinants,
and the European Union and
Transcribed Image Text:60
55
50
45
0
5
10
Most deprived
S518 Editorial
15
World Health Organization have
also acted on the social determi-
nants of health and adopted this
approach at the heart of their
health improvement and health
equity strategies. There have also
been advancements at the national
Life expectancy
DFLE
Pension age increase 2026-2046
level-in many countries national
governments have acted. There
have been some great strides by
local governments and authorities
too. In England, 75% of local au-
thorities have adopted this approach.
However, and it is a significant
however, there are many further
challenges to greater health equity
and to the social determinants of
health.
UNDERSTANDING HEALTH
The association between health
and health care is so strong that
many politicians and people as-
sume that health and health care
are the same. Until health and
nonhealth stakeholders (and the
public) start demanding that gov-
ernments implement greater, more
effective action to improve health
and reduce inequities through ac-
tion outside the health care sector,
it is likely that this important dis-
tinction will continue to be lost.
20
BEHAVIOR AND HEALTH
25
There has been great, and in-
creasing, focus on unhealthy be-
haviors that drive ill health. This
approach sees that individuals are
largely responsible for their own
health and can improve health
through better health behaviors-
largely more sensible drinking
and eating and not smoking.
ever, we need to understand
and improve the social determi-
nants of behaviors to reduce
health inequalities and improve
health while simultaneously trying
to facilitate and support better
existing behaviors.
30
Source. Reprinted with permission from The Marmot Review.
FIGURE 2-Life expectancy and disability-free life expectancy (DFLE) at birth by neighborhood income and deprivation: 1999-2003.
35 40 45 50 55 60 65
Neighbourhood Income Deprivation
(Population Percentiles)
EVIDENCE
POLITICS
EDITORIAL
There is an abundance of evi-
dence showing the relationships
between social and environmental
factors and a whole raft of health
outcomes. There is also plenty of
evidence about what to do and
what works best internationally,
nationally, and at local levels. We
have plenty of practical evidence
about short and long-term action
at a variety of administrative
levels, for different populations
and for countries at different
levels of development in different
parts of the world. Citing a lack of
knowledge about what to do is
simply no longer credible. Cost
benefit evidence is harder to pro-
vide, as evaluations are complex,
outcomes long term, and the
equity implications often over-
looked. Notwithstanding all of
this, there is enough cost benefit
evidence to show that many in-
terventions are efficient, equita-
ble, and effective when designed
and delivered in the right way.
Moreover, and most importantly,
the case is moral-reducing health
inequities and improving health is
a duty and should be a priority for
governments and those with in-
fluence to improve health.
70 75 80 85
The objections and challenges
to taking action on the social de-
terminants of health are often in-
tensely political. It is sometimes
argued that it is not the govern-
ment's responsibility to enforce
changes of behaviors, but just
to provide information, so that
everyone is equally well informed,
if that were possible. It s not
simply ideology that contradicts
this view. The facts are against it.
Poverty, rising inequality in in-
come and assets, and social ex-
clusion all drive widening and
Source: Office for National Statistics
deepening health inequalities in
many countries. The generation
and distribution of wealth in
a country through income and
welfare policy, in particular, re-
flects political priorities.
Much can be done to improve
health and reduce gross health
inequities. Some of this comes
from provision of universal health
care, designed to be equitable in
access and outcomes-as the VHA
has worked toward. But changes
must also come from wider social
and economic changes and re-
ductions in inequalities, and many
governments, civil society organi-
zations, and others have shown
the will to act to great effect.
Greater impact requires greater
action and will. As well as working
toward more equitable provision,
public health and the medical
workforce have critical roles to
play in social and political advo-
cacy at all levels, helping lead
more equitable health, and social
and economic, systems-and we
welcome the contributions on
furthering equity in this supple-
ment.
Michael Marmot, PhD
Jessica J. Allen, PhD
American Journal of Public Health | Supplement 4, 2014, Vol 104, No. S4
About the Authors
The authors are with the Institute of Health
Equity, University College London, London,
UK.
90 95
Correspondence should be sent to Jessica
J. Allen, Deputy Director, Institute of Health
Equity, UCL, 1-19 Torrington Place,
London, WCIE 7HB, United Kingdom
(e-mail: jessica.allen@ucl.ac.uk). Reprints
can be ordered at http://www.ajph.org by
clicking the "Reprints" link.
This article was accepted July 2, 2014.
doi:10.2105/AJPH 2014.302200
Contributors.
Both authors contributed equally to this
editorial.
Least deprived
References
1. Commission on Social Determinants
of Health. CSDH Final Report: Closing
the Gap in a Generation: Health Equity
100
Through Action on the Social Determinant
of Health. Geneva, Switzerland: World
Health Organization; 2008.
2. Hunter DJ, Popay J, Tannahill C,
Whitehead M, Elson T. Learning Lessons
From the Past: Shaping a Different
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marmot-review-working-committee-3-
report/working-committee-3-final-report.
pdf. Accessed June 17, 2014.
3. Davis K, Stremikis K, Squires D.
Schoen C. (2014) Mirror, Mirror on the
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Health Care System Compares Internation-
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-/media/files/publications/fund-report/
2014/jun/1755_davis_mirror_mirror_
2014.pdf. Accessed July 11, 2014.
4. Broader determinant of health. The
King's Fund. Available at: http://www.
kingsfund.org.uk/time-to-think-differently/
trends/broader-determinants-health.
Accessed June 18, 2014.
5. Robert Wood Johnson Foundation.
Commission to Build a Healthier America.
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commissiononhealth.org/Publications.
aspx. Accessed July 11, 2014.
6.
The Marmot Review. Fair Society,
Healthy Lives: Strategic Review Health
Inequalities in England Post-2010.
London, UK: The Marmot Review; 2010.
7. Marmot M. Status Syndrome: How
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Health London, UK: Bloomsbury Pub-
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