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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 

 

 

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: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
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 Future. Marmot Review Working Com- mittee 3. Cross-cutting sub-group re- port. 2009. Available at: https://www. instituteofhealthequity.org/projects/the- 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 Wall: How the Performance of the US Health Care System Compares Internation- ally. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/ -/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. 2008. Available at: http://www. 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 Your Social Standing Directly Affects Your Health London, UK: Bloomsbury Pub- lishing Plc; 2004.
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 Future. Marmot Review Working Com- mittee 3. Cross-cutting sub-group re- port. 2009. Available at: https://www. instituteofhealthequity.org/projects/the- 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 Wall: How the Performance of the US Health Care System Compares Internation- ally. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/ -/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. 2008. Available at: http://www. 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 Your Social Standing Directly Affects Your Health London, UK: Bloomsbury Pub- lishing Plc; 2004.
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