Social inequalities in health and closing the gap in a generation

Unravelling mechanisms underlying the action principles of a community-based health promotion programme: a realist evaluation

BACKGROUND

Since 1986, WHO has advised that applying action principles such as citizen participation and intersectoral collaboration leads to better health. However, less is known about the workability of these principles and how they trigger specific outcomes in interaction with the context. A critical realist perspective was applied to get a better understanding of what worked, and why it worked, in the context of a Dutch community-based health promotion programme (CBHPP). The aim of the study was to unravel the mechanisms underlying the action principles and find combinations of contextual factors and mechanisms that trigger outcomes in a CBHPP.

METHODS

In this single case study, a critical realist methodology was followed. Qualitative data used in this study originated from multiple sources and methods to ensure validity. They include evaluation sessions with coalition members (n = 6) and individual interviews (n = 6); group sessions with community workers (n = 1), a health broker (n = 1), and citizens (n = 12); and seven semi-annual progress reports and minutes of the coalition meetings. The collected data were then compared with the programme theory through a heuristic process of constructing, exploring, and refining context-mechanism-outcome configurations.

RESULTS

The programme initiated a variety of new activities that differed in content, intensity, duration, and number of participants, organised and implemented together with citizens. The most prominent mechanism underlying both action principles were programme-related, namely, patience, personal contact, contribution of budget, and the programme coordinator's leadership. Another important mechanism was creating visibility, which resulted in the involvement of the municipality and a budget to sustain the programme.

CONCLUSION

In this case study, personal contact, patience, perseverance, participatory action research activities, and visibility were found to be the most notable mechanisms underlying the citizen participation and intersectoral collaboration action principles. As the principle-based approach added value to the existing context and introduced most of the mechanisms that triggered the outcomes, it is recommended to include citizen participation and intersectoral collaboration not only as action principles but explicitly as targets in a CBHPP.

"We Don't Assume That Everyone Has the Same Idea About Health, Do We?" Explorative Study of Citizens' Perceptions of Health and Participation to Improve Their Health in a Low Socioeconomic City District

In community health promotion programs that aim to reduce health inequities, citizen participation is recommended, as it strengthens citizens’ active involvement and has a positive impact on health. A prerequisite for citizen participation is recognizing and incorporating citizens’ perceptions of health. Therefore, this study aimed to explore these perceptions and actions needed to improve the health of citizens living in a low socioeconomic city district. Concept mapping was used to actively engage community members as part of the action research method. Eleven community groups (n = 89 citizens) together with community workers participated in the study. Participants in all groups agreed that health entails more than the absence of disease, and therefore it is a multidimensional concept. Social relations, physical activity, positive life attitude, healthy eating, and being in control were important perceptions about health. Although the participants were aware of the relation between lifestyle and health, actions to improve health included doing things together, collaboration, self-confidence, focusing on possibilities, and socially shared meanings. Creating a supportive environment to address health behavior appeared to be the most important action for citizens to facilitate behavior change. Concept mapping helped to involve citizens and provided community workers with valuable information to shape the program together with citizens.

Study protocol: evaluation of a community health promotion program in a socioeconomically deprived city district in the Netherlands using mixed methods and guided by action research

BACKGROUND

Voorstad on the Move (VoM) is a community health promotion program implemented in a socioeconomically deprived city district in the Netherlands. Based on exploration of the health situation, concurrent views on health promotion, and insights from literature, VoM is grounded in a social-ecological perspective and puts three action principles center core: citizens' participation, intersectoral collaboration, and a health supportive environment. VoM aims to improve the health of inhabitants, mostly low socioeconomic status (SES) families, and to realize changes in the social and physical environment. This current research, as part of the wider VoM project, aims to study the impacts and action principles of VoM. The main research questions concern the inhabitants' perceptions on health and health supportive environments, the perceived benefits of citizen participation in terms of health literacy and empowerment, and the factors and mechanisms that contribute to citizen participation and intersectoral collaboration.

METHODS

The study has a mixed methods design, including process evaluation and monitoring, and combines qualitative and quantitative data. Research activities include literature study, in-depth interviews, focus group discussions, concept and capacity mapping, document analysis, and health survey data. A prominent strategy is action research, which aims to involve all stakeholders, capturing the different perspectives of citizens and professionals, and engaging low SES groups. The principle of triangulation is continuously applied to optimize the reliability of this study, using multiple methods and multiple sources. Internal validity is enhanced by triangulation of methods and resources. Other verification techniques will also be used, such as expert consultation.

DISCUSSION

The design of the study, with a strong focus on action research, facilitates the involvement of all stakeholders and contributes to the development of capacities, learning, and empowerment, and thus contributes to health. The VoM program is innovative because it adopts an open approach in which activities evolve from citizens' needs, with a focus on action elements. This study will unravel the mechanisms of the action elements at community level, thereby helping to find ways to reduce health inequities. The findings will further elucidate what works and why it works for low SES groups.

Taking stock of the social determinants of health: A scoping review

BACKGROUND

In recent decades, the social determinants of health (SDOH) has gained increasing prominence as a foundational concept for population and public health in academic literature and policy documents, internationally. However, alongside its widespread dissemination, and in light of multiple conceptual models, lists, and frameworks, some dilution and confusion is apparent. This scoping review represents an attempt to take stock of SDOH literature in the context of contemporary population and public health.

METHODS

We conducted a scoping review to synthesize and map SDOH literature, informed by the methods of Arksey and O'Malley (2005). We searched 5 academic and 3 grey literature databases for "social determinants of health" and "population health" or "public health" or "health promotion," published 2004-2014. We also conducted a search on "inequity" or "inequality" or "disparity" or "social gradient" and "Canad*" to ensure that we captured articles where this language was used to discuss the SDOH. We included articles that discussed SDOH in depth, either explicitly or in implicit but nuanced ways. We hand-searched reference lists to further identify relevant articles.

FINDINGS

Our synthesis of 108 articles showed wide variation by study setting, target audience, and geographic scope, with most articles published in an academic setting, by Canadian authors, for policy-maker audiences. SDOH were communicated by authors as a list, model, or story; each with strengths and weaknesses. Thematic analysis identified one theme: health equity as an overarching and binding concept to the SDOH. Health equity was understood in different ways with implications for action on the SDOH.

CONCLUSIONS

Among the vast SDOH literature, there is a need to identify and clearly articulate the essence and implications of the SDOH concept. We recommend that authors be intentional in their efforts to present and discuss SDOH to ensure that they speak to its foundational concept of health equity.

[Changes in public health: the role of the state and the autonomous governments. SESPAS Report 2010]

The first responsibilities in health passed on to the autonomous governments were those referring to public health. However, the decentralization process has not been accompanied by an updated management of the collective efforts to promote and protect health, or by a greater weight of public health within the system. To carry out such a reform, public health authorities and the central and autonomic administrations must assume their corresponding roles. The leading role should correspond to the central administration and includes the coordination and evaluation of the entire process, while the regional public health authorities should be in charge of providing public health services to the population, promoting innovations, and collaborating among themselves as well as with the central administration. Recent legal initiatives show some political sensitivity and may provide an opportunity, in addition to those provided by the economic crisis, to emphasize the role of guarantor rather than that of supplier for the state. Paradoxically, the marginality of public health could facilitate the necessary political agreements, even though party interests may be an obstacle. The influence of professional associations could be important.