⛑️Public Health Ethics Unit 4 – Health Equity and Social Determinants

Key Concepts in Health Equity

• Health equity involves ensuring everyone has a fair opportunity to attain their full health potential
• Achieving health equity requires removing obstacles to health (poverty, discrimination, powerlessness, lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care)
• Health disparities refer to differences in health outcomes and their causes among groups of people
  • Often driven by social, economic, and environmental disadvantages
  • Examples include higher rates of chronic diseases in low-income communities
• Health inequities are disparities in health that are avoidable, unfair, and unjust
  • Stem from systemic issues such as racism, discrimination, and unequal distribution of resources
• Social justice is a key principle in health equity
  • Emphasizes the fair distribution of health resources and outcomes across society
• Health equity is not the same as health equality
  • Equality aims to provide everyone with the same resources
  • Equity recognizes that different groups may need different resources to achieve optimal health

Social Determinants of Health Explained

• Social determinants of health (SDOH) are non-medical factors that influence health outcomes
• SDOH include income and social status, education, physical environment, employment, social support networks, and access to health services
• Income and social status greatly impact health
  • Higher income often correlates with better health outcomes
  • Poverty limits access to healthy food, safe housing, and quality healthcare
• Education is linked to better health outcomes
  • Higher levels of education are associated with healthier behaviors and longer life expectancy
• Physical environment affects health
  • Poor air and water quality, unsafe housing, and lack of green spaces can negatively impact health
• Employment and working conditions impact health
  • Job insecurity, low wages, and hazardous work environments can lead to poor health outcomes
• Social support networks provide emotional and practical resources
  • Strong social connections can buffer against stress and promote healthy behaviors
• Access to health services is crucial for maintaining good health
  • Barriers such as cost, transportation, and language can limit access to care

Historical Context and Development

• The concept of social determinants of health gained prominence in the 1970s and 1980s
  • Researchers began to recognize the limitations of focusing solely on individual behaviors and medical care
• The Lalonde Report (1974) was a landmark document in Canada
  • Identified four key determinants of health: biology, environment, lifestyle, and healthcare
• The Black Report (1980) in the United Kingdom highlighted the role of social class in health inequalities
  • Demonstrated that health disparities persisted despite the establishment of the National Health Service
• The World Health Organization (WHO) has played a significant role in promoting health equity
  • The Ottawa Charter for Health Promotion (1986) emphasized the importance of social and environmental factors in health
  • The Commission on Social Determinants of Health (2005-2008) produced a comprehensive report on the impact of SDOH globally
• The Marmot Review (2010) in England further solidified the evidence base for SDOH
  • Proposed strategies for reducing health inequities through action on SDOH
• In the United States, Healthy People 2020 and 2030 have included SDOH as key focus areas
  • Aim to "create social and physical environments that promote good health for all"

Ethical Frameworks for Health Equity

• Utilitarianism focuses on maximizing overall health outcomes for the greatest number of people
  • Prioritizes interventions that produce the greatest net benefit to society
  • May justify redistributing resources to disadvantaged groups if it improves overall health
• Egalitarianism emphasizes the equal distribution of health resources and outcomes
  • Argues that everyone should have equal access to the social determinants of health
  • Supports policies that level the playing field and reduce disparities
• Prioritarianism gives priority to improving the health of the worst-off groups
  • Holds that we have a greater moral obligation to help those with the greatest need
  • Favors targeted interventions for disadvantaged populations
• Sufficientarianism aims to ensure that everyone achieves a sufficient level of health
  • Focuses on bringing everyone above a minimum threshold of health and well-being
  • May prioritize resources for those below the threshold
• Capability approach emphasizes the importance of enabling people to achieve their full potential
  • Views health as essential for individuals to pursue their life goals and values
  • Supports policies that enhance people's capabilities and freedoms
• Human rights framework recognizes health as a fundamental human right
  • Obligates governments to respect, protect, and fulfill the right to health
  • Emphasizes non-discrimination, participation, and accountability in health policies

Health Disparities: Causes and Consequences

• Health disparities are driven by complex interactions between social, economic, environmental, and structural factors
• Racism and discrimination contribute to health disparities
  • Racial and ethnic minorities often face barriers to accessing quality healthcare, education, and employment
  • Experiences of discrimination can lead to chronic stress and negative health outcomes
• Socioeconomic status (SES) is a major determinant of health disparities
  • Lower SES is associated with poorer health outcomes and shorter life expectancy
  • SES affects access to resources such as healthy food, safe housing, and quality education
• Neighborhood and built environment play a role in health disparities
  • Low-income communities often have limited access to healthy food options, green spaces, and safe places for physical activity
  • Exposure to environmental hazards (air pollution, lead) is more common in disadvantaged neighborhoods
• Health literacy and language barriers can exacerbate health disparities
  • Limited health literacy can lead to poor disease management and adherence to treatment plans
  • Language barriers can hinder communication with healthcare providers and access to health information
• Health disparities result in significant economic and social costs
  • Increased healthcare expenditures due to preventable illnesses and complications
  • Lost productivity and reduced quality of life for individuals and communities
  • Perpetuation of cycles of poverty and disadvantage across generations

Intersectionality and Health Outcomes

• Intersectionality recognizes that individuals have multiple, intersecting identities (race, gender, class, sexuality, disability status)
  • These identities interact to shape unique experiences of privilege and oppression
  • Intersectional approach examines how multiple forms of discrimination and disadvantage compound to affect health
• Gender and health intersect in complex ways
  • Women often face unique health challenges (reproductive health, gender-based violence)
  • Gender norms and roles can influence health behaviors and access to care
• Race and ethnicity intersect with other social determinants to shape health outcomes
  • Racial and ethnic minorities are more likely to experience poverty, discrimination, and limited access to resources
  • Historical and ongoing systemic racism contributes to health disparities
• Socioeconomic status interacts with other identities to influence health
  • Low-income individuals from marginalized groups may face multiple barriers to health
  • Intersection of poverty and minority status can amplify health risks and challenges
• LGBTQ+ individuals face distinct health disparities
  • Stigma and discrimination can lead to mental health issues and substance abuse
  • Barriers to accessing culturally competent and affirming healthcare
• Disability status intersects with other identities to shape health experiences
  • People with disabilities often face barriers to accessing healthcare and social support
  • Intersection of disability and other marginalized identities can compound health challenges

Policy Approaches to Addressing Health Inequities

• Health in All Policies (HiAP) integrates health considerations into decision-making across sectors
  • Recognizes that policies in housing, transportation, education, and other areas impact health
  • Promotes collaboration between public health and other sectors to improve health equity
• Place-based initiatives target interventions to specific communities or neighborhoods
  • Address social, economic, and environmental factors that contribute to health disparities
  • Examples include community development, affordable housing, and access to green spaces
• Universal healthcare coverage ensures that everyone has access to quality, affordable healthcare
  • Reduces financial barriers to accessing preventive care and treatment
  • Can help reduce health disparities by providing a basic level of care for all
• Targeted interventions focus resources on populations with the greatest health needs
  • Tailored approaches to address specific barriers and challenges faced by disadvantaged groups
  • Examples include culturally competent healthcare, language assistance services, and community health workers
• Policies to address social determinants of health tackle upstream factors that influence health
  • Investments in education, employment, and social welfare programs can improve health outcomes
  • Policies to reduce poverty, discrimination, and social exclusion are critical for health equity
• Community engagement and empowerment strategies involve communities in decision-making processes
  • Ensure that policies and interventions are responsive to community needs and priorities
  • Foster trust, build capacity, and promote sustainable change

Practical Applications and Case Studies

• The Adverse Childhood Experiences (ACE) Study demonstrated the lifelong impact of childhood trauma on health
  • ACEs are linked to increased risk of chronic diseases, mental illness, and substance abuse
  • Interventions to prevent and mitigate the effects of ACEs can promote health equity
• The Whitehall Studies in the United Kingdom examined the relationship between social class and health
  • Found a clear social gradient in health outcomes, with lower occupational status associated with poorer health
  • Highlighted the importance of addressing social and economic factors to improve health equity
• The Alameda County Public Health Department in California has implemented a place-based approach to health equity
  • Focuses on improving social, economic, and environmental conditions in disadvantaged neighborhoods
  • Initiatives include affordable housing, community gardens, and violence prevention programs
• The Bronx Health REACH program in New York City aims to reduce racial and ethnic disparities in health
  • Engages community members, healthcare providers, and faith-based organizations to promote health equity
  • Interventions include nutrition education, physical activity programs, and access to healthy food options
• The REACH Healthcare Foundation in Kansas City focuses on improving access to quality healthcare for underserved populations
  • Supports initiatives to increase health insurance coverage, improve language access services, and enhance cultural competency in healthcare
• The Richmond Health Equity Partnership in Virginia brings together diverse stakeholders to address health inequities
  • Develops community-driven solutions to improve social determinants of health
  • Initiatives include workforce development, transportation access, and school-based health services