Policy implications Flashcards
Woolf & Braveman. (2011). Where health disparities begin: The role of social and economic determinants - and why current policies may make matters worse.
Gist: Downstream determinants of health are often shaped by upstream societal factors. Downstream determinants can include medical care, environmental factors, & health behaviors. There’s recent evidence of a gradient for income & health (and education & health).
Neighborhoods & communities: unhealthy behavior is partially personal choice, research has shown that environment in which people live & work also makes an impact.
Biological pathways: Repeated exposure can produce “wear and tear” on organs & precipitate particular diseases in life; genes can be modified by environment.
Declining incomes & increasing inequality: poverty rate in U.S. has been climbing & gap between rich & poor has been widening; compared to other industrialized nations, we have a declining ranking of life expectancy & highest health care costs.
Policies, macroeconomics, & social structure: Health can be best addressed through policies that improve economic opportunity, vibrancy of neighborhoods, & access to education & income (conditions set by society & not by health care system)
“Health in all policies” movement: Link between social policy & health
Braveman, Egerter, & Williams. (2011). The social determinants of health: Coming of age.
Gist: Medical care alone cannot improve overall health nor reduce health disparities. Upstream & downstream social determinants of health: causal pathways linking upstream determinants w/downstream determinants.
Neighborhood conditions & health: influence health via physical characteristics & availability & quality of neighborhood services
Working conditions & health: Physical & psychosocial aspects of work
Education & health: 3 pathways - (1) health knowledge & healthy behaviors, (2) shaping of employment opportunities, (3) influencing social & psychological factors.
Income, wealth, & health: reflects both access to material goods & services & wealth
Race, racism, & health: constrains some individuals’ opportunities & resources by race/ethnicity
Pervasive role of stress: chronic stress implicated in causal pathways linking multiple upstream social determinants via neuroendocrine, inflammatory, immune, and/or vascular mechanisms; may trigger the release of cortisol, cytokines, & other substances that can damage immune defenses, vital organs, & physiologic systems.
Health effects can be impacted across lifetimes & generations: (1) early childhood experiences, (2) intergenerational transfer of advantage & health.
Krieger. (2001). Theories for social epidemiology in the 21st century: An ecosocial perspective.
Gist: Focuses on 3 theoretical frameworks for research in social epidemiology.
Psychosocial theory: Social environment alters individual’s susceptibility by affecting neuroendocrine/other biological functioning (e.g., marginal status in society, asset of social support)
Social production of disease/political economy of health: uses “upstream-downstream” metaphor; economic & political institutions create, enforce, & perpetuate economic & social privilege & inequality are “fundamental causes” of social inequalities in health; environmental justice movement
Ecosocial theory & related multilevel dynamic perspectives: integrates “fundamental causes” of health & how these are embodied biologically; approach is concerned with scale (dimensions of spatiotemporal phenomenon), level of organization (nested hierarchies), dynamic states (interplay of inputs & outputs), mathematical modelling, & understanding unique phenomena in relation to general processes; social production of disease perpesctive
Minkler. (2013). Linking science and policy through community-based participatory research to study and address health disparities.
Gist: Focuses on a number of community-based participatory research projects. It’s been used more often to address persistent health disparities. Two concepts that are relevant: distributive justice and procedural justice.
Distributive justice: Relate to disproportionate lack of access to resources or assets (e.g., safe recreation areas, stores selling high-quality & affordable fresh fruits & veggies)
Procedural justice: Equitable processes through which low-income communities of color, rural residents, & other marginalized groups can gain a seat at the table (& stay at the table) to have a real voice in decision making
Challenges to CBPR: (1) policy work involves multiple players leveraging numerous points (complex); (2) likelihood of policy victory influenced by changes in policy environment; (3) CBPR partners may be reluctant to discuss policy-related work for fear funding precludes activity on this level; (4) tendency of mass media to single out one contribute (often a politician) to “credit” for a policy victory & potential among CBPR partners to over- or under-state their own perceived role; (5) policy changes take place over a long time period, making evaluation challenging.
Chin, Walters, Cook, & Huang. (2013). Interventions to reduce racial and ethnic disparities in health care.
Gist: Provide a conceptual model for interventions to reduce disparities & review key findings. Multifactorial, culturally tailored interventions that target different causes of disparities hold the most promise. In the model, recognizing that individuals go back & forth between being persons in the community & patients in a health care organization. Important events can occur in both settings to influence processes of care & outcomes. The role of the community is also critical; the bulk of patient self-management of chronic illness takes place in the community (e.g., monitoring symptoms, taking medications, participating in programs of exercise & nutrition). Additionally, persons are surrounded by social networks of peers & families that influence attitudes & behavior, & healthy choices are influenced by environmental factors. Interventions that create linkages between communities & health care systems may improve access to care & subsequently improve health status. Examples: national policy interventions that provide health insurance, use of community health workers or promotoras, etc. Need to seamlessly integrate 2 worlds of community & health care organization environments.
Glass & McAtee. (2006). Behavioral science at the crossroads in public health: Extending horizons, envisioning the future.
Gist: Proposed 3 innovations to integrate the natural & behavioral sciences in study of behavior & health. Generally, behavioral intervention studies ignore the social context & physiological consequences of behavior change seldom considered.
1) Expand, modify, & “unpack” the stream of causation metaphor - increased emphasis on social determinants on health behaviors
2) Address issues related to causal reasoning - “fundamental causes” are not causally meaningful but are related to health
3) Propose a new type of variable: “risk regulator” - mostly treated as potential confounders; risk regulator is a relatively stable feature of a particular path of social & built environments, residing at levels of organization above individual but below larger-scale macrosocial levels; not themselves risks but conditions that regulate or control exposure probabilities to distal behaviors (and non-behavioral risks) that lead to disease; similar to “fundamental causes” except they’re not causes but characteristics of social context that help explain accumulation & distribution of causes.
Examples of potential risk regulators: material conditions; discriminatory practices, policies, & attitudes; neighborhood & community conditions; conditions of work; behavioral norms, rules, & expectations; laws, policies, & regulations
Taylor-Clark, Mebane, Steelfisher, & Blendon. (2007). News of disparity: Content analysis of news coverage of African American healthcare inequalities in the USA, 1994-2004.
Gist: While public awareness of healthcare inequalities in the US has increased, the public has become less supportive of federal responsibility to address healthcare inequalities. Agenda setting literature suggests that news coverage may have an impact on public awareness of an issue & public support for government responsibility to address the issue. Prominence of coverage of racial healthcare inequalities increased between 1994-2004 & journalists increasingly used academics, academic reports, experts, advocacy groups, & Republican politicians as sources of information. However, to reduce healthcare inequalities, public support for federal government responsibility will be needed to develop sustainable public policy.
Lurie. (2002). What the federal government can do about the nonmedical determinants of health.
Gist: The healthcare delivery system contributes proportionally less to health when compared to the environment & behavior, making a need to address nonmedical determinants of health. Some steps the US government can take to address these factors & related challenges include:
Leadership & education: Educating the general public & policymakers in states & communities about the role determinants play.
Surgeon general’s report: Educate nation & stimulate action on key health issues.
Policy development among sectors: Standing mechanisms for policy development among sectors could be created to continuously help policymakers understand & take advantage of opportunities to address health via nonmedical determinants.
Interdepartmental collaboration: Interdepartmental collaborations to influence nonmedical determinants.
Monitoring & reporting: Major federal policy lever is management of informational environment in which agendas & priorities are set.
Strengthening the science base: Ned more about mechanisms through which nonmedical determinants (esp. related to SES & social conditions) affect health.
Leveraging government as an employer: Federal government is nation’s largest employer & 80% work outside of DC.
Expanding scope of health policy: Would facilitate consideration of health-promoting interventions.
Holmes et al. (2008). Challenges for multilevel health disparities research in a transdisciplinary environment.
Gist: Numerous factors play a part in health disparities. Although health disparities manifest at individual level, other contexts should be considered when investigating associations of disparities within clinical outcomes. The Centers for Population Health & Health Disparities program was established by NIH to examine the highly dimensional, complex nature of disparities & effects on health. Challenges categorized along 3 axes: sources of subjects & data, data characteristics, & multilevel analysis & interpretation.
