Social determinants of health are becoming a dominant way of thinking about public health issues and their solution. In the recently released Final Report of the WHO Commission on Social Determinants of Health, the authors state:
...inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces...The Commission calls on the WHO and all governments to lead global action on the social determinants of health with the aim of achieving health equity. It is essential that governments, civil society, WHO, and other global organizations now come together in taking action to improve the lives of the world’s citizens. Achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it.
At a 2008 meeting convened by the Prevention Institute and Trust for America’s Health, a group of government officials, community advocates, and researchers discussed the US government’s role in addressing underlying determinants of health. Their recommendations were:
1. Establish high-level leadership in the federal departments and at the White House to serve as a focal point for prevention strategy and to ensure collaboration between government agencies to enhance underlying determinants of health.
2. Engage key federal sectors and agencies that shape the conditions that determine health in collaborative efforts.
3. Redirect funding streams to increase investment in prevention.
4. Implement a system of accountability that establishes clear responsibilities and incentives for contributing to improved population health.
5. Establish a data and evaluation system to monitor progress and focus public attention on the importance of determinants of health.
6. Establish a strong system of training and skill building for staff at all levels of government to engage in determinants of health work.
7. Translate a determinants of health focus to states and localities.
8. Build political will to successfully propose and implement such changes.
At the June meeting of the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 they endorsed as part of the revised mission statement for Healthy People 2020: Increasing public awareness and understanding of the underlying causes of health, disease, and disability. The point is that social determinants are rapidly becoming the lingua franca for the new public health (maybe 30 years later than originally envisioned, but OK).
Shifting the perspective of public health policy-makers, researchers and practitioners will be one set of challenges. An equally important group of questions will focus on how to communicate about social determinants with the public in ways that make it relevant to them and offer opportunities to improve their own health. After decades of public health messages that have focused on individual knowledge, attitudes and behaviors, this will be no easy task. That is what made this study on message design strategies to raise public awareness of social determinants of health interesting for me. From the author's abstract:
This article reviews three message strategies that could be used to raise awareness of SDH [social determinants of health] and health disparities: message framing, narratives, and visual imagery. FINDINGS: Although few studies have directly tested message strategies for raising awareness of SDH and health disparities, the accumulated evidence from other domains suggests that population health advocates should frame messages to acknowledge a role for individual decisions about behavior but emphasize SDH. These messages might use narratives to provide examples of individuals facing structural barriers (unsafe working conditions, neighborhood safety concerns, lack of civic opportunities) in efforts to avoid poverty, unemployment, racial discrimination, and other social determinants. Evocative visual images that invite generalizations, suggest causal interpretations, highlight contrasts, and create analogies could accompany these narratives. These narratives and images should not distract attention from SDH and population health disparities, activate negative stereotypes, or provoke counterproductive emotional responses directed at the source of the message.
The authors conclude by noting, and I reinforce, The time has arrived to begin thinking systematically about issues in communicating about SDH and health disparities. I will also add that there is a much broader social marketing perspective that should be applied to this issue.
The shift in thinking about what the determinants of health and disease are, from ones that are individually based to ones that are social in nature, challenges social marketers to awake to the idea that we are in the business of social change and not simply changing the behavior of individuals. It also points to the important perspective and role we can bring in engaging with policy-making bodies, organizations and programs to broaden their ideas and activities about what is important to focus on to improve the health of all people everywhere.
[Ed Note: Image of the main elements The Ottawa Charter for Health Promotion, 1986.]
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