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Unformatted text preview: Contents Health Promotion Journal of Australia Volume 17, Number 3, December 2006 Editorials Equity and the social determinants of health 163 Fran Baum and Liz Harris A global perspective on health promotion and the social determinants of health 165 David Sanders The social determinants of health: what are the three key roles for health promotion? 167 Dennis Raphael Are social determinants of health the same as societal determinants of health? 170 Barbara Starfield Policy Building healthy and equitable societies: what Australia can contribute to and learn from the Commission on Social Determinants of Health 174 Fran Baum and Sarah Simpson Social determinants, political contexts and civil society action: a historical perspective on the Commission on Social Determinants of Health 180 Orielle Solar and Alec Irwin The role of the People’s Health Movement in putting the social determinants of health on the global agenda 186 Ravi Narayan* The social determinants of health: is there a role for health promotion foundations? 189 Barb Mouy and Ali Barr The role of health promotion: between global thinking and local action 196 Lesley King The health system: what should our priorities be? Editorial office 210 Anne-marie Boxall and Stephen R. Leeder Equity, by what measure? 206 Shane Houston Sustainable communities: what should our priorities be? 211 Valerie A. Brown and Jan Ritchie Research Federal, State and Territory government responses to health inequities and the social determinants of health in Australia 217 Please address all editorial correspondence, including original contributions to: The Editor Health Promotion Journal of Australia PO Box 351, North Melbourne, Victoria 3051, Australia Phone: (03) 9329 3535 Fax: (03) 9329 3550 E-mail: [email protected] Internet: Guidelines for authors are available in each issue of the Journal and on the AHPA website. Lareen Newman, Fran Baum and Elizabeth Harris Smoking, not smoking: how important is where you live? 226 Christine Migliorini and Mohammad Siahpush Evaluation of the Outreach School Garden Project: Building the capacity of two Indigenous remote school communities to integrate nutrition into the core school curriculum 233 Antonietta Viola Scoping supermarket availability and accessibility by socio-economic status in Adelaide Lisel A. O’Dwyer and John Coveney 240 The Health Promotion Journal of Australia gratefully acknowledges the support of the University of the Sunshine Coast in hosting the Secretariat of the Australian Health Promotion Association. Contents Food insecurity in three socially disadvantaged localities in Sydney, Australia Book Review 247 Michelle Nolan, Glenys Rikard-Bell, Mohammed Mohsin and Mandy Williams Utility stress as a social determinant of health: exploring the links in a remote Aboriginal community 255 Eileen Willis, Meryl Pearce, Carmel McCarthy, Tom Jenkin and Fiona Ryan Point of View The war on obesity: a social determinant of health 262 Lily O’Hara and Jane Gregg Community Research in Environmental Health: Studies in Science, Advocacy and Ethics 268 By Doug Brugge and H. Patricia Hynes. Reviewed by Cordia Chu Index Health Promotion Journal of Australia Volume 17, 2006 – Author Index 269 Health Promotion Journal of Australia Volume 17, 2006 – Subject Index 271 Reviewers Social determinants of health and health inequalities: what role for general practice? 264 Health Promotion Journal of Australia Reviewers in 2006 273 John Furler The NSW Social Determinants of Health Action Group: influencing the social determinants of health 266 Suzanne Gleeson and Garth Alperstein Health Promotion Journal of Australia Journal of the Australian Health Promotion Association (Inc) © Australian Health Promotion Association ISSN 1036-1073 The Journal is indexed by Australian Public Affairs Information Service (APAIS), CINAHL, MEDLINE/Index Medicus, EMBASE, EMNURSING, Compendex, GEOBASE, PROQUEST, Scopus and Sociological Abstracts. It has been assessed by the Commonwealth Department of Education Science and Training as satisfying the refereeing requirements for the Higher Education Research Data Collection (HERDC). Previous issues are available at Matter published in the Journal does not necessarily represent the views of the Australian Health Promotion Association. Joint Editors Editorial Advisory Board Chris Rissel BSc MPH PhD Health Promotion Unit, Sydney South West Area Health Service, NSW, and School of Public Health, University of Sydney, Level 9, King George V, Missenden Road, Camperdown, New South Wales 2050 E-mail: [email protected] Jan Ritchie DipPhty MHPEd PhD School of Public Health and Community Medicine, University of New South Wales, Kensington, New South Wales 2052 Adrian Bauman MBBS MPH PhD FAFPHM Professor of Health Promotion, School of Public Health, University of Sydney, New South Wales 2006 Gauden Galea Regional Office for the Western Pacific, World Health Organization, Philippines Billie Giles-Corti Department of Public Health, University of Western Australia Elizabeth Harris School of Public Health and Community Medicine, University of New South Wales T. H. Lam Department of Community Medicine, The University of Hong Kong Lily O’Hara Faculty of Science, Health and Education University of the Sunshine Coast Mihi Ratima Division of Public Health and Psychosocial Studies, Auckland University of Technology, New Zealand 162 Health Promotion Journal of Australia 2006 : 17 (3) Trevor Shilton National Heart Foundation, Western Australia Louise Signal Department of Public Health University of Otago, New Zealand K. C. Tang Department of Non-communicable Disease Prevention and Health Promotion, World Health Organization, Switzerland Book Review Editor Ben Smith School of Public Health, University of Sydney, New South Wales ‘Exploring Technical Issues’ Editor Elizabeth Parker School of Public Health, Queensland University of Technology Editorials Guest Editors This theme issue of the Journal focuses on a critical but surprisingly neglected aspect of health promotion practice, the social determinants of health. As Guest Editors, Liz Harris and Fran Baum have done an absolutely outstanding job in attracting high quality papers and overseeing the reviewing and revision processes. They have delivered, on time, not only the largest ever issue of the Journal, but a substantial contribution to the international health promotion literature. Many, many thanks from the Joint Editors! Chris Rissel, Adrian Bauman and Jan Ritchie Equity and the social determinants of health Fran Baum and Liz Harris This special issue comes at a time when interest in the social determinants of health is increasing internationally. In the face of rapid economic globalisation and the emergence of significant infectious and chronic health problems of potentially pandemic proportions, the social and economic effects of public and private sector policies on health and its determinants are becoming too stark to ignore. During the 20th Century life expectancy increased significantly. Between 1901 and 2001, life expectancy at birth rose by 23 years for men and 24 years for women in Australia.1 Yet while there have been absolute increases in life expectancy for most groups around the world, considerable inequalities remain between people from different social classes, ethnic backgrounds and gender. Many of these differences result from differential access to the conditions that promote health, such as employment, education and basic health hardware such as safe drinking water, waste disposal and sanitation systems, these differences can be considered unfair or inequitable. The promotion of health across populations and ensuring that this is done in a manner that reduces these inequities is crucial. We agree with Starfield’s editorial that much of the research and comment on the social determinants of health does not have an equity focus and that it should do so. Recognition of the importance of the social determinants of health is not new. The public health reformers of the 19th Century clearly recognised their importance. Among the most progressive, the Silesian doctor Virchow, was clear that the health of workers in the 1840s was directly related to the working conditions they experienced.2 The sanitary reforms in 19thCentury Britain were based on an understanding that environmental conditions had a direct affect on health. The work of McKeown noted that the 20th-Century life expectancy improvements had more to do with changing living conditions than to do with medical therapies.3 Szreter’s analysis added further to the understanding that local government civic reforms played a crucial role in the environmental improvement.4 These reforms did not just happen as a matter of course, but often resulted from significant social and class struggle.5,6 That there is a new focus on social determinants in the early 21st Century may reflect the fact that the current form of economic globalisation is tending to increase inequities within and between countries,7,8 and the logic of focusing on social and economic change is compelling. Public health has largely assumed that life expectancy would continue to rise. The experience of several regions of the world now negate that expectation and, from a global perspective, sustainable and equitable health advancement is not yet secure. In Africa, an HIV/AIDS pandemic has resulted in falls in life expectancies in many countries.8 In eastern Europe, following the fall of the Soviet Union and the rapid introduction of market reforms, life expectancies of men fell.9 Predictions are being made that in the rich countries younger generations may experience falling life expectancies compared with their baby boomer parents because of increased chronic diseases, partly attributable to the impact of the ways in which the social and built environment are affecting physical activity and nutrition.10 The formation of the Commission on the Social Determinants of Health by the World Health Organization in 2005 is a clear sign of the recognition that there needs to be greater focus on these upstream determinants or, as the Commission has called them, the “causes of the causes”.11 The Commission has positioned itself as emerging from the tradition of Alma Ata and the Ottawa Charter, as Solar and Irwin make clear in their paper on the historical legacy inherited by the Commission. This legacy is also noted by Baum and Simpson in their paper, which cites as examples of early actions on social determinants the work of past Australian governments such as Menzies federally and Dunstan at the State level in South Australia. The Commission will report in 2008 and is challenging countries to base their public health policies on an understanding of the importance and centrality of the social determinants of health to improving health equitably. A social determinants approach poses many challenges for health promoters. Perhaps most significantly, much health promotion starts with a focus on individuals and, in the past, has been strongly associated with attempts to change behaviour. The limitations of this approach have been noted,12 but the individualism associated with it still dominates much health promotion research and practice. While some attempts to change behaviour have met with success (such as smoking and reducing fat consumption), the focus on individuals has been supported by policy change and has had more success with better-off people. Thus, the net effect has been to increase inequities. The social determinants require a focus on policies, organisations and social structure. Some papers in this issue provide evidence of a shift in focus. Migliorini and Siahpush consider how where you live may affect your likelihood of smoking. Viola looks at Health Promotion Journal of Australia 2006 : 17 (3) 163 Editorials the question of how schools integrate nutrition into core school curriculum in remote Indigenous communities. Willis et al considers the importance of the cost and supply of an essential service such as electricity, ODwyer and Coveney detail the existence of food deserts in Adelaide, and Nolan et al looks at the factors behind food insecurity. In each case, these pieces of research do not focus directly on individual health or health status but look upstream to how the structures people live in shape their health experience. This should be an increasing focus of health promotion research so that we develop a better evidence base about the “causes of the causes” of illness and about the factors that create health and well-being. The ways in which the social determinants affect the health of individuals is obviously complex – the “causes of the causes” requires looking upstream to social and economic structures that shape our chances of health and illness. Unlike behaviours that are evident and obvious, these structures are largely invisible in everyday life. These structures need to be recognised and the history, values and assumptions on which they have been based clearly understood. King demonstrates the need for this to change and for health promotion to be a sustained effort. Mouy and Barr point to the important work done by the Victorian Health Promotion Foundation in shaping programs around the structures that determine behaviours rather than the behaviours themselves. The commissioning of this issue on the social determinants by the Australian Health Promotion Association reflects its growing leadership in focusing on social determinants and equity as a means of promoting health. This is very welcome and further development of this work encouraged. While most health is created outside the formal health sector (that can more accurately be described as an illness care sector), this sector does have a vital role as the place in government that has a particular responsibility for health. Boxall and Leeder call for significant reform to the operation of health systems that would include more co-ordination and focus on health promotion. Newman et al. review the action each Australian jurisdiction takes in regard to health inequity and demonstrates that Australia can still claim to be one of the world leaders in terms of social determinants action for equity, but that our performance is patchy. There is certainly much room for improvement. A focus on the social determinants of health has to be seen in a global context because so many of the determinants themselves are affected by global trends. This is reflected in contributions in this issue. Sanders demonstrates the massive inequities in health that exist globally but especially in sub-Saharan Africa. He argues very convincingly that the global economy does not promote health for the majority of the world’s population and is the most fundamental determinant of health. He particularly sees global trading patterns as in need of reform. Brown and Ritchie point to the global nature of the environmental crisis we face, rightly noting that unless action for sustainability is taken humans face a bleak future on this planet. 164 Health Promotion Journal of Australia 2006 : 17 (3) Given that the distribution of the social determinants will always have to be argued for against powerful forces whose interests may be threatened, the need for advocacy is a common theme in many of the papers in this collection. Sanders discusses the need for social mobilisation to advocate against unfair trade. Baum and Simpson suggest that the Commission on the Social Determinants of Health provides a great opportunity for advocates to use the work of the Commission and its Knowledge Networks as a powerful advocacy instrument in arguing for policy change. They also note that the Commission is one of the first such bodies to involve civil society in a central way. King argues that health promotion has a responsibility to undertake advocacy for social change. Irwin and Solar show that the history of social determinants has been one of social struggle before positive change is achieved. Narayan points to the growing People’s Health Movement as a vibrant network of social movements that take action on the social and economic determinants of health as fundamental to improving the health of the world’s poorest people. Gleeson and Alperstein point to the work of a New South Wales-based advocacy group that is bringing together professional associations to look at how they can collectively lobby for change. Furler writes about the potential role of general practitioners and their professional associations. Our hope is that the coming years will see action on the social determinants of health as part of the core business of health systems. Across the world it is being recognised that this action will be based on across-government action. This raises important questions about who should take responsibility for ensuring this co-ordination happens and that progress towards improved and more equitable health is monitored. Such leadership is difficult for our existing health systems. However, there are some signs that this may be changing as the social and economic benefits of preventing chronic health problems, developing systems to combat emerging infectious disease, and addressing health inequity are outweighing the costs of inaction. Across Australia we are beginning to see some evidence that these issues are being taken seriously. Investment in cross-sectoral programs in the early years of life, community strengthening and crime prevention programs, the promotion of physical activity and improvements in urban design are signs of this change. The extent to which the health sector can lead or value add to the work of other sectors on these issues will require change in priorities and practice. The lessons from history would suggest that this change will take time, be contested, and require change in the ways in which we all think about what we are doing. In the short term, this may involve lobbying for a specific proportion of health budgets to be allocated to prevention and early intervention, bi-annual reporting of progress against an agreed set of cross-sector social indicators for health and well-being, and open debates on the values upon which we want our society to be built. In the longer term, health promoters need to be Editorials advocates and implementers of policies that will create a fair and just society where opportunities for health are equitably distributed. References 1. Australian Institute of Health and Welfare [subject areas – mortality page on the Internet]. Canberra (AUST): Commonwealth of Australia; 2006 [cited 2006 Nov 4]. Life Expectancy. Overview. Available from: expectancy.cfm 2. Virchow R. Papers on health. In: Rather LJ, editor. Collected Essays on Public Health and Epidemiology. 2 volumes. Canton (MA): Science History Publications; 1985. 3. McKeown T, Brown RG. Medical evidence related to English population changes in the eighteenth century. Popul Stud (Camb). 1955;19:119-41. 4. Sretzer S. The importance of social interventions in Britain’s mortality decline c. 1850-1914: a re-interpretation of the role of public health. Social History of Medicine. 1988;1:1-37. 5. Doyal L. The Political Economy of Health. London (UK): Pluto Press; 1979. 6. Muntaner C. Commentary: Social Capital, Social Class and the slow progress of psychosocial epidemiology. Int J Epidemiol. 2004;33:1-7. 7. Labonte R, Schrecker T, The Globalization Knowledge Network. Globalisation and the Social Determinants of Health: Analytic and Strategic Review Paper. Ottawa (CAN): Institute of Population Health; 2005. Available from: social_determinants/resources/globalization.pdf 8. Sen K, Bonita R. Global health status: two steps forward, one step back. Lancet. 2000;356(9229):577-82. 9. Notzon FC, Komarov YM, Ermakov SP, Sempos CT, Marks JS, Sempos EV. Causes of declining life expectancy in Russia. J Am Med Assoc. 1998;279:793-800. 10. Olshansky ...
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