Health policy approaches to population health: the limits of medicalization

Trends and structural factors affecting health equity in the United States at the local level, 1990-2019

Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

Diagnosing social ills: Theorising social determinants of health as a diagnostic category

Medicine, as an institution and discipline, has embraced social determinants of health as a key influence on clinical practice and care. Beyond simply acknowledging their importance, most recent versions of the International Classification of Diseases explicitly codify social determinants as a viable diagnostic category. This diagnostic shift is noteworthy in the United States, where 'Z-codes' were introduced to facilitate the documentation of illiteracy, unemployment, poverty and other social factors impacting health. Z-codes hold promise in addressing patients' social needs, but there are likely consequences to medicalising social determinants. In turn, this article provides a critical appraisal of Z-codes, focussing on the role of diagnoses as both constructive and counterproductive sources of legitimacy, knowledge and responsibility in our collective understanding of health. Diagnosis codes for social determinants are powerful bureaucratic tools for framing and responding to psychosocial risks commensurate with biophysiological symptoms; however, they potentially reinforce beliefs about the centrality of individuals for addressing poor health at the population level. I contend that Z-codes demonstrate the limited capacity of diagnoses to capture the complex individual and social aetiology of health, and that sociology benefits from looking further 'upstream' to identify the structural forces constraining the scope and utility of diagnoses.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

The Perils of Medicalization for Population Health and Health Equity

Policy Points Medicalization is a historical process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and "diagnosed and treated" as individual pathologies and problems by medical authorities. Medicalization in the United States has led to a conflation of "health" and "health care" and a confusion between individual social needs versus the social, political, and economic determinants of health. The essential and important work of population health science, public health practice, and health policy writ large is being thwarted by a medicalized view of health and an overemphasis on personal health services and the health care delivery system as the major focal point for addressing societal health issues and health inequality. Increased recognition of the negative consequences of a medicalized view of health is essential, with a focus on education and training of clinicians and health care managers, journalists, and policymakers.

The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis

BACKGROUND

With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions.

OBJECTIVE

This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity.

METHODS

This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level.

RESULTS

The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis.

CONCLUSIONS

The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health.

Contributions of Hippocratic medicine and Plato to today's debate over health, social determinants and the authority of biomedicine

By exploring a competition for authority on health and human nature between Plato and Hippocratic medicine, this paper offers a fresh perspective on an overarching debate today involving health and the role of healthcare in its safeguarding. Economically and politically, healthcare continues to dominate the USA's handling of health, construed biophysically as the absence of disease. Yet, notoriously, in major health outcomes, the USA fares worse than other countries in the Organisation for Economic Co-operation and Development (OECD). Clearly, in giving pre-eminence to healthcare, the USA is doing far less than it could to protect and improve health. Meanwhile, mounting evidence supports the view that health impacts of social determinants besides healthcare (eg, education) surpass healthcare in heft. Circumscribed shifts in the USA's current frame will not suffice: what's needed is a change in its overall template for addressing health. Unless this is widely seen, the sway of biomedicine will likely be reduced slowly, if at all. That biomedicine's role in relation to health is raised increasingly as a question is a sign that its ongoing supremacy is not a forgone conclusion. But making the most of this opportunity requires appreciating that 'How should health's relationship to medicine be conceptualised?' is not the most fundamental query that we need to pose. Through consideration of Hippocratic medicine and Plato, I argue that the most availing answer to this particular question can come only after exploration of three larger questions involving health's status as a human good and its relationship to human flourishing. Exploration of the Greeks is, thus, valuable methodologically. What's more, it supports today's advocacy of 'health promotion', a perspective tying health closely to well-being that has yet to achieve the overall prominence that it warrants.

Social risk, health inequity, and patient safety

Social factors that affect health are called social determinants. Social determinants may also carry risk, known as social risk. Management and patient safety professionals understand health care and enterprise risk. Social risk may add a new dimension for some. Social risks are probably amenable to the strategies patient safety and risk management professionals already employ, such as enterprise risk management, a culture of safety, and just culture. A large body of evidence suggests that social risks, particularly literacy and discrimination, strongly affect patient safety and well-being. This paper examines the relationship between social determinants of health and social risks and considers how health care organizations might address literacy and discrimination from the perspective of patient safety and risk management.

Examining U.S. Newspapers’ Effects on COVID-19 Infection Rates Among Racial/Ethnic Minorities

Background: The coronavirus disease 2019 (COVID-19) pandemic reveals health disparities in the United States. News media are expected to play a major role in reducing racial/ethnic disparities.

Methods: Guided by agenda-setting theory in the context of health promotion and the structural approach of media effects, this study assessed the impacts of COVID-19 newspaper articles about racial/ethnic minorities on minorities' infection rates in the early stages of the pandemic, while controlling for social determinants of health (SDOHs).

Results: Racial/ethnic minorities are underrepresented in COVID-19 newspaper articles, although newspapers' attention to racial/ethnic minorities' health increased over time. Public exposure to newspaper articles about racial/ethnic minorities was the only significant factor that predicted infection rates among general racial/ethnic minorities. The more the general public in the United States was exposed to related newspaper articles, the lower the infection rates among general racial/ethnic minorities would be. The impacts of SDOHs varied across different racial/ethnic minority groups. Blue states were more likely to be exposed to COVID-19 newspaper articles about racial/ethnic minorities than red states.

Discussion: Findings suggest that news exposure to any racial/ethnic group can benefit all minorities. Findings also demonstrate the influence of media agenda on public agenda and policy agenda regarding minority health.

Health Power Resources Theory: A Relational Approach to the Study of Health Inequalities

Link and Phelan's pioneering 1995 theory of fundamental causes urged health scholars to consider the macro-level contexts that "put people at risk of risks." Allied research on the political economy of health has since aptly demonstrated how institutions contextualize risk factors for health. Yet scant research has fully capitalized on either fundamental cause or political economy of health's allusion to power relations as a determinant of persistent inequalities in population health. I address this oversight by advancing a theory of health power resources that contends that power relations distribute and translate the meaning (i.e., necessity, value, and utility) of socioeconomic and health-relevant resources. This occurs through stratification, commodification, discrimination, and devitalization. Resurrecting historical sociological emphases on power relations provides an avenue through which scholars can more fully understand the patterning of population health and better connect the sociology of health and illness to the central tenets of the discipline.

Air pollution and life expectancy in Europe: Does investment in renewable energy matter?

This study examines the relationship between health and air pollution using a novel approach that allows differentiation between potential and observed health. It also permits an analysis of those factors that may contribute towards reducing any differences between the latter concepts. To this end, a panel data from 29 European countries for the periods 2005 and 2018 is used. Results indicate that the main pollutants affecting European countries, namely NOx, PM10 and PM2.5 have a negative impact on life expectancy at birth, while investment in renewable energies has a positive effect. Several conclusions can be drawn from these results. Firstly, if the aim is to minimize the detrimental effects of the global production of goods and services on air quality, a greater investment in renewable energies as compared to other more polluting ones, is called for. In turn, this would contribute to an improvement in the general health of citizens and the planet thereby increasing overall potential life expectancy. Secondly, NOx gases seem to be the ones that most affect the population's mean potential life expectancy. Results indicate that with regard to particulate matters, those with a diameter of less than 2.5 μm, are the ones that have the greatest impact on the health of European citizens, more so than larger particles (with a diameter between 10 and 2.5 μm).

Immigrant Health Inequities: Exposing Diversions and White Supremacy

Diversions occur when research disregards the inequality-generating actions of advantaged groups and instead focuses attention on the actions and behaviors of disadvantaged groups. We incorporate important insights from COVID-19 to illustrate historical and contemporary examples of diversions. This paper highlights US immigrant health inequities—a burgeoning subfield within the broader health inequalities canon—to explore: (1) if and how diversions appear in immigrant health studies; (2) how often white supremacy and intersectionality are explicitly named in grants, publicly available datasets, and published research. The data derive from: NIH R01 grants (17), publicly available datasets that focus on immigrant health (7), and research published in three health journals (14). Using a qualitative content analysis approach, we analyzed these data as evidence concerning the knowledge production cycle, and investigate whether: (a) the role of advantaged groups in generating inequalities is explicitly mentioned; (b) disadvantaged groups are asked about discriminatory actions perpetuated by advantaged groups; (c) health inequalities are placed on the conditions of disadvantaged groups; (d) if white supremacy and intersectionality are explicitly mentioned in grants, publicly available datasets, and research articles. The findings demonstrate the prevalence of diversions in immigrant health research, given an overemphasis on health behaviors and cultural explanations towards explaining immigrant health inequities. There was no mention of white supremacy across the knowledge production cycle. Intersectionality was mentioned once in a research article. We argue that understanding white supremacy’s role in the knowledge production cycle illuminates how diversions occur and prevail. We provide suggestions on moving away from diversionary research, toward adopting an intersectional approach of the study of immigrant health inequities.

The Roots of Structural Racism in the United States and their Manifestations During the COVID-19 Pandemic

During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect pre-existing structural inequities. Structural racism is racial discrimination rooted in history, perpetuated through policies, and manifested in disparities in healthcare, housing, education, employment, and wealth. Although these disparities exert greater impacts on health outcomes than do genetics or behavior, scientists, and policy makers are only beginning to name structural racism as a key determinant of population health and take the necessary steps to dismantle it. In radiology, structural racism impacts how imaging services are utilized. Here we review the history and policies that contribute to structural racism and predispose minority and disadvantaged communities to inferior outcomes during the COVID-19 pandemic in order to identify policy changes that could promote more equitable access to radiologic services.

Individual responsibilities, collective issues: The framing of dietary practices in Latvian media

Topics concerning food and diets have gained prominence in academic writing, policy debates and media coverage, not least due to public health problems, sedentary lifestyles, and concerns regarding dietary habits and the impact of food production on climate change. The purpose of this paper is to reveal the ways dietary practices have been framed in the media through an analysis of Latvian print and digital media articles. A selection of 192 media articles published between 2014 and 2019 were analysed through the perspective of framing. The analysis identifies three prominent frames found in Latvian media: (i) a biomedical frame, (ii) a psychological frame, and (iii) a social practice frame. The frames are connected by several cross-cutting themes: individualisation, self-disciplining, gendering, and medicalisation. The results suggest that the media portray unhealthy dietary as the responsibility of individuals, whilst ignoring, with some exceptions, the impact of broader societal and food system processes. These results call for more attention to be paid by media content creators to the diversity of actors involved in food production, consumption and distribution and their inter-connections, as well as the impact that food systems have on economic, social, and ecological sustainability.

The obesity paradigm and the role of health services in obesity prevention: a grounded theory approach

Background

Health services have a clear role in the treatment of obesity and diseases linked to obesity but a less well-established role in prevention, particularly in hospital and community-based health services.

Methods

The aim of this research was to examine whether and how hospital and community-based health services incorporate adult obesity prevention into policy and practice. The case study setting was an Australian based health service. Grounded theory informed all aspects of the research including participant recruitment, data collection and data analysis. A systems approach guided the analysis of diverse perspectives, relationships and interconnections within the study context.

Results

The prevailing paradigm within the health service is that obesity is a matter of choice. This dominant perspective combined with a disease focused medical model overly simplifies the complex issue of obesity and reinforces the paradigm which treats obesity as a matter of individual responsibility. A focus on individual change hinders health services from playing an effective role in obesity prevention and leads to unintended consequences, including increasing stigma.

Conclusions

Health service responses to obesity and its prevention compound the negative elements associated with obesity for individuals and are ineffective in creating positive change at individual or a societal level. An alternative systems-level approach is needed to align health service responses with contemporary approaches that address obesity prevention as a complex problem.

Behavioural and structural interventions in cancer prevention: towards the 2030 SDG horizon

Traditionally, the prevention of cancer (and other chronic diseases) has been considered primarily linked to personal responsibility, for which interventions must be based on health education information enabling individuals to make knowledge‐based decisions to improve their lifestyle. However, lifestyle is conditioned by environmental factors (including dimensions such as the context of economics, transport, urbanism, agriculture or education) that may render healthy behavioural choices either easier or, alternatively, impossible. This article reviews the conceptual underpinnings of the behavioural‐structural dichotomy. We believe that it is advisable to opt for multilevel strategies that take into account all the determinants of health, using structural and behavioural approaches, rather than only the latter, as has been done until now.

The Potential and Realized Impact of the Affordable Care Act on Health Equity

The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion.

Princípios invocados numa política intersetorial de saúde: o caso da fluoretação da água no Brasil

Resumo O objetivo foi identificar princípios invocados numa política intersetorial de saúde, tomando como caso uma proposta legislativa de revogação da fluoretação da água no Brasil apresentada em 2003. Realizou-se estudo descritivo por meio de pesquisa documental, na qual foram selecionados registros gerados na tramitação do Projeto de Lei nº 510/2003 na Câmara dos Deputados. Buscou-se destacar estratégias discursivas utilizadas pelos atores conforme o jogo de interesses e o contexto conflitivo, utilizando-se o institucionalismo histórico como referencial teórico. O Projeto de Lei tramitou 13 meses, passando pelo Plenário, por três comissões, e sendo arquivado. Três deputados de partidos distintos, órgãos do Poder Executivo federal, agências reguladoras e entidades representativas da categoria odontológica, da saúde pública/coletiva, da engenharia sanitária e das empresas de saneamento participaram diretamente do debate em que emergiram os princípios da segurança da intervenção, dos custos econômicos e do direito à saúde. Em relação às estratégias discursivas utilizadas, os principais elementos invocados no debate da política intersetorial de saúde foram o princípio da incerteza, criando-se falsas categorias científicas a fim de sobrevalorizar os efeitos desfavoráveis e sustentar a implementação de medidas individualizantes; e os princípios morais que definem diferentes tipos de bens econômicos e dimensões de liberdade associadas ao exercício de direitos.

Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach

Background

Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care.

Methods

We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan’s National Health Insurance system from 2000 to 2016. Patient’s income levels were categorized into low-income group (<25th percentile) and high-income group (≥25th percentile). We used marginal structural modeling analysis to calculate the odds of hospital admissions for 11 ambulatory care sensitive conditions identified by the Agency for Healthcare Research and Quality and the odds of having an Elixhauser comorbidity index greater than zero for low-income patients.

Results

Among 2,844,334 patients, those in lower-income group had 1.28 greater odds (95% CI 1.24–1.33) of experiencing preventable hospitalizations, and 1.04 greater odds (95% CI 1.03–1.05) of having a comorbid condition in comparison to high-income group.

Conclusions

Income was shown to be a causal factor in a patient’s health and a determinant of the quality of care received even with equitable access to care under a universal health insurance system. Policies focusing on addressing income as an important upstream causal determinant of health to provide support to patients in lower socioeconomic status will be effective in improving health outcomes for this vulnerable social stratum.

Issues Relevant to Population Health in Political Advertising in the United States, 2011-2012 and 2015-2016

Policy Points Political advertising can influence which issues are public policy priorities. Population health-relevant issues were frequently referenced in televised political advertising in the 2011-2012 and 2015-2016 US election cycles, with about one-fourth of all ads aired mentioning traditional public health and health policy topics and more than half referencing broader determinants of population health. The volume of population health-relevant issues referenced in political ads varied by geography, political office, political party, and election cycle. Ads referencing broader determinants of population health (such as employment, education, or gender equality) rarely tied these determinants directly to health outcomes.

CONTEXT

Political discourse is one way that policymakers and candidates for public office discuss societal problems, propose solutions, and articulate actionable policies that might improve population health. Yet we know little about how politicians define and discuss issues relevant to population health in their major source of electoral communication, campaign advertisements. This study examined the prevalence of references to population health-relevant issues conveyed in campaign advertising for political office at all levels of government in the United States in 2011-2012 and 2015-2016. Understanding advertising as part of the political discourse on topics of relevance to population health yields insights about political agenda-setting and can inform efforts to shape opinion.

METHODS

We conducted a content analysis of all English-language, candidate-related campaign advertisements aired on local broadcast, national network, and national cable television in the 2011-2012 and 2015-2016 election cycles (3,980,457 and 3,767,477 airings, respectively). We analyzed the volume of coverage in these ads about issues relevant to population health, including narrowly defined public health issues as well as a broad range of other social, economic, and environmental factors that affect population health.

FINDINGS

Across both election cycles and all electoral races, 26% of campaign advertising discussed issues relevant for the narrowly defined conceptualization of public health and 57% discussed issues pertinent to topics within the more expansive population health conceptualization. There was substantial variation in population health-related content in ads across election cycles, by level of political office, political party, and geographic area. Geographic variation indicates that where a person lives affects their potential exposure to political communication about various health-related topics.

CONCLUSIONS

Political campaign ads in the United States frequently referenced population health-relevant content at all levels of government, although the ads rarely connected population health-relevant issues to health. Variation in volume and content of these references likely shaped public opinion and the public will to address population health-related policy.

Homelessness, health and the policy process: A literature review

Homelessness has serious consequences for the health of people experiencing homelessness, and presents a challenge to the provision of quality care by health services. Policymaking to address homelessness, as with other social determinants of health (SDH), is complicated by issues of complex causation, intersectoral working and the dominance of biomedicine within health policy. This paper investigates how policies addressing homelessness have been explored using formal policy process theories (PPT). It also examines how health (as an actor and an idea) has intersected with the issue of homelessness reaching policy agendas and in policy implementation. A systematised search of academic databases for peer-reviewed literature from 1986 to 2018 identified six studies of homelessness policy change from Australia, Canada, France and the United States. PPT were able to articulate the interplay of actors, ideas and structures in homelessness policymaking. When the health sector was involved, it tended to be in terms of healthcare service utilisation rather than a broader public health framework emphasising structural social determinants of homelessness. Tensions between differing the priorities of local homelessness actors and a biomedical evidence-based policy paradigm were noted. Future policy action on homelessness requires new models of intersectoral governance that account for the complexity of health determinants, a health workforce enabled to engage with the SDH, and meaningful inclusion of those with lived and living experience of homelessness in policy formulation.

Reframing inequality? The health inequalities turn as a dangerous frame shift

Background

Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but European governments have for the most part failed to enact policies that would reduce underlying social inequalities.

Methods

Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health inequalities policies.

Results

Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.

Conclusions

Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.

Government Health and Social Services Spending Show Evidence of Single-Sector Rather Than Multi-Sector Pursuit of Population Health

Population health improvements can be achieved through work made possible by government spending on health care, public health, and social services. The extent to which spending allocations across these sectors is synergistic with or trade-off against one another is unknown. Achieving a balanced portfolio with multi-sector contributions is key to improving health outcomes. This study tested competing hypotheses regarding achievement of balanced multi-sector resources for health. County-level U.S. Census Bureau data on all local governmental spending measured each county’s average per capita local government spending for public hospitals, public health, social services, and education. American Hospital Association (AHA) Annual Survey data on hospital community health service provision were used to calculate an index of hospital community service provision aggregated to county level by year. County Health Rankings data measured each county’s health outcomes and health factors. Longitudinal mixed-effects regression models (n = 1877 counties) predicted changes in spending for each government spending category based on two sets of predictors (government spending vs community health services and needs) from current and prior year. Models account for average spending in each category and county-, state-, and time-trends. Models showed that spending increases in each of the four spending categories examined (public hospitals, public health, social services, and education) were not associated with changes in spending across other categories in current or prior years. For all categories, an increase from baseline spending levels in Year 1 was always significantly associated with an increase from baseline spending level in that same category in Year 2 (ie, spending stayed above baseline in Year 2). Multi-sector initiatives to health outcomes require funding across sectors, yet there was little evidence to suggest that communities that invest in public hospitals, public health, or other social services see commensurate increases in other areas. Underlying funding decisions may reflect strategic decisions within a community to scale up single sectors, constrained resources for multi-sector scale up, or a host of additional factors not measured here.

The Role of Community Health Needs Assessments in Medicalizing Poverty

The Patient Protection and Affordable Care Act (ACA), passed in 2010, is considered by many to be the most significant healthcare overhaul since the 1960s, but part of its promise - improvement of population health through requirements for non-profit hospitals to provide "community benefit" - has not been met. This paper examines the history of community benefit legislation, how community benefit dollars are allocated, and innovative practices by a few hospitals and communities that are addressing primarily non-medical factors that influence health such as social disadvantage, attitudes, beliefs, risk exposure, and social inequalities.

MEDICALIZAÇÃO, DESMEDICALIZAÇÃO, POLÍTICAS PÚBLICAS E DEMOCRACIA SOB O CAPITALISMO

Resumo A expansão da influência da medicina sobre problemas sociais e questões morais tem sido objeto de intensas discussões, mas muitos especialistas reclamam que a análise tem perdido rigor. Neste ensaio, recuperamos os sentidos mais profundos do termo medicalização e discutimos duas hipóteses inter-relacionadas: se as políticas públicas com impacto positivo sobre os níveis de saúde populacional cumpririam um papel desmedicalizante e se o aprofundamento da democracia poderia ser considerado uma condição imprescindível para enfrentar os processos medicalizantes. Com base na literatura, identificam-se conceitos nucleares relacionados às principais forças motrizes dos processos de medicalização e também mudanças associadas ao controle aumentado sobre a natureza que modifica a vida como a conhecemos, e destaca-se o avanço da ordem econômica capitalista sobre outras esferas como o Estado e a comunidade. Diante deste contexto, argumenta-se que qualquer perspectiva desmedicalizante de longo alcance dependeria ao menos de duas hipóteses inter-relacionadas que correspondem ao modelo que orienta a resposta às necessidades de saúde e à força da democracia em seu duplo sentido, seja como categoria política capaz de colocar os setores majoritários da sociedade no centro das decisões do Estado, seja como categoria econômica capaz de alterar os efeitos econômicos do capitalismo nas relações Estado-sociedade.

Pay For Success And Population Health: Early Results From Eleven Projects Reveal Challenges And Promise

Pay for success (PFS) is a type of social impact investing that uses private capital to finance proven prevention programs that help a government reduce public expenditures or achieve greater value. We conducted an analysis of the first eleven PFS projects in the United States to investigate the potential of PFS as a strategy for financing and disseminating interventions aimed at improving population health and health equity. The PFS approach has significant potential for bringing private-sector resources to interventions regarding social determinants of health. Nonetheless, a number of challenges remain, including structuring PFS initiatives so that optimal prevention benefits can be achieved and ensuring that PFS interventions and evaluation designs are based on rigorous research principles. In addition, increased policy attention regarding key PFS payout issues is needed, including the "wrong pockets" problem and legal barriers to using federal Medicaid funds as an investor payout source.

Physical therapists familiarity and beliefs about health services utilization and health seeking behaviour

BACKGROUND

Physical therapists' familiarity, perceptions, and beliefs about health services utilization and health seeking behaviour have not been previously assessed.

OBJECTIVES

The purposes of this study were to identify physical therapists' characteristics related to familiarity of health services utilization and health seeking behaviour, and to assess what health seeking behaviour factors providers felt were related to health services utilization.

METHODS

We administered a survey based on the Andersen behavioural model of health services utilization to physical therapists using social media campaigns and email between March and June of 2017. In addition to descriptive statistics, we performed binomial logistic regression analysis. We asked respondents to rate familiarity with health services utilization and health seeking behaviour and collected additional characteristic variables.

RESULTS

Physical therapists are more familiar with health services utilization than health seeking behaviour. Those who are familiar with either construct tend to be those who assess for health services utilization, use health services utilization for a prognosis, and believe that health seeking behaviour is measurable. Physical therapists rated need and enabling factors as having more influence on health services utilization than predisposing and health belief factors.

CONCLUSION

Physical therapists are generally familiar with health services utilization and health seeking behaviour; however, there appears to be a disconnect between what is familiar, what is perceived to be important, and what can be assessed for both health services utilization and health seeking behaviour.

Does Medical Expansion Improve Population Health?

Medical expansion has become a prominent dynamic in today's societies as the biomedical model becomes increasingly dominant in the explanation of health, illness, and other human problems and behavior. Medical expansion is multidimensional and represented by expansions in three major components of the healthcare system: increasing medical investment, medical professionalization/specialization, and the relative size of the pharmaceutical industry. Using Organisation for Economic Co-operation and Development health data and World Development Indicators 1981 to 2007, we find medical investment and medical professionalization/specialization significantly improve all three measures of life expectancy and decrease mortality rate even after controlling for endogeneity problems. In contrast, an expanded pharmaceutical industry is negatively associated with female life expectancy at age 65 and positively associated with the all-cause mortality rate. It further compromises the beneficial effect of medical professionalization/specialization on population health. In general, medical professionalization/specialization and gross domestic product per capita have similar and stronger effects than medical investment.

The growth and development of gerontological nurse leaders in policy

BACKGROUND

The National Hartford Center of Gerontological Nursing Excellence (NHCGNE) Scholars/Fellows Award Program was designed to promote the growth and development of nurse scientists, educators, and leaders in aging.

PURPOSE

McBride's conceptual framework of the growth and development of nurse leaders was used to examine the NHCGNE impact on health and aging policy work among scholars/fellows, including barriers, facilitators, and resources.

METHODS

A multimethod two-phased approach included an online survey (phase I) focused on research and policy impact at local, state, or national level. Telephone interviews (phase II) were conducted to further understand the nature, depth, and focus of respondents' policy work.

DISCUSSION

Based on our findings, we propose multilevel recommendations for advancing nurse scientists' capacity to be leaders in shaping policy. Keen research skills are influential in policy advancement but not sufficient to advance policy. Preparing nurse scientists with competencies in translating research into policy can ultimately transform health and health care for older adults.

Shelter from the Storm: Roles, responsibilities, and challenges in United States housing policy governance

Housing is a critical social determinant of health. Housing policy not only affects health by improving housing quality, affordability, and insecurity; housing policy affects health upstream through the politics that shape housing policy design, implementation, and management. These politics, or governance strategies, determine the successes or failures of housing policy programs. This paper is an overview of challenges in housing policy governance in the United States. I examine the important relationship between housing and health, and emphasize why studying housing policy governance matters. I then present three cases of housing governance challenges in the United States, from each pathway by which housing affects health - housing quality, affordability, and insecurity. Each case corresponds to an arm of the TAPIC framework for evaluating governance (Krieger and Higgins) [1], to assess mechanisms of housing governance in each case. While housing governance has come a long way over the past century, political decentralization and the expansion of the submerged state have increased the number of political actors and policy conflict in many areas. This creates inherent challenges for improving accountability, transparency, and policy capacity. In many instances, too, reduced government accountability and transparency increases the risk of harm to the public and lessens governmental integrity.

China's National Health Guiding Principles: a perspective worthy of healthcare reform

For countries faced with much talk but little action on healthcare reform, China's National Health Guiding Principles (CNHGP), with its 60-year history, may provide a new perspective. There are four values of CNHGP for healthcare reform. First, these principles provide an innovative strategic framework for healthcare reform with three levels, from 'One priority population' to 'Four approaches' and then to 'Two aims.' The second is the importance of mass/grassroots participation, which runs through all three levels of CNHGP. The third value is that the CNHGP used nonspecific social approaches, an innovation in healthcare delivery that addressed the social determinants of health. The fourth value is the integration between Chinese traditional medicine and Western medicine.

Making a distinction between the effect of initial stock and investment in health determinants

The objective of this paper was to propose a health production model that distinguishes between the initial stock of health determinants and the subsequent investment in them, with a view to providing information to policy-makers regarding the effects of determinant-aimed policies. In this sense, the main contributions of the paper stem from the development of a theoretical and empirical model that distinguishes between the effect of the initial stock and that of investment in health determinants. To do this, we estimated the health production function using a stochastic frontier model. We present an empirical example using data for the years 2002 and 2008. The results support our decision to analyse the effects of the initial values attributable to health determinants separately from those arising following investment in the period. Concretely, we find significant differences for the determinants EMPLOY, SOCIALCLASS and NON-DRINKER. The results seem to indicate that, for variables labelled with the behavioural aspects of health such as NON-DRINKER, the effect over time of a change in investment in health is significantly greater than that resulting from a variation in initial values. In contrast, for socioeconomic variables such as SOCIAL CLASS or EMPLOY, for which effects on health tend to be more long-term in nature, the opposite occurs, with the effect of the investment during the time period proving significantly lower than the effect of the initial provision.

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

The medicalization of obesity, bariatric surgery, and population health

This article examines how the medicalization of obesity validates the use of bariatric surgery to treat obesity in the United States and how expansions in access to bariatric surgery normalize surgical procedures as disease treatment and prevention tools. Building on this discussion, the article poses two questions for population health regarding health technology: (1) to what extent does bariatric surgery treat obesity in the United States while diverting attention away from the ultimate drivers of the epidemic and (2) to what extent does bariatric surgery improve outcomes for some groups in the US population while simultaneously generating disparities? We conduct a brief, historical analysis of the American Medical Association’s decision to reclassify obesity as a disease through internal documents, peer-reviewed expert reports, and major media coverage. We use medicalization theory to show how this decision by the American Medical Association channels increased focus on obesity into the realm of medical intervention, particularly bariatric surgery, and use this evidence to review research trends on bariatric surgery. We propose research questions that investigate the population health dimensions of bariatric surgery in the United States and note key areas of future research. Our objective is to generate a discourse that considers bariatric surgery beyond the medical realm to better understand how technological interventions might work collectively with population-level obesity prevention efforts and how, in turn, population health approaches may improve bariatric surgery outcomes.

The study of processes of medicalization in Latin America

In recent decades, an ever-increasing cluster of phenomena has attracted the attention of social scientists and historians of medicine: processes of medicalization. As in other regions, Latin America has been affected by these phenomena. This article surveys recent literature involving sociological studies of these processes in the region, in order to provide an overview of the issue. It explores the theoretical transformations linked to the concept of medicalization in the contexts where they originated. It then analyzes the ways in which the concept has been appropriated by the social sciences in Latin America in order to describe the various phenomena associated with medicalization in the subcontinent.

Why has medicine expanded? The role of consumers

In the past 50years, the field of medicine has expanded dramatically in many Western societies. Despite substantial improvements in objective health measures, there has not been a commensurate increase in assessments of subjective health. We hypothesize that medical expansion may lower people's subjective health perceptions, leading to an increase in health care utilization, and, in turn, fueling further medical expansion. We use OECD (Organization for Economic Co-operation and Development) Health Data, World Development Indicators, the World Values Survey, and the European Values Study to fit a difference-in-differences model that removes unobserved cross-national heterogeneity and any period trend that is shared across nations. We find that three dimensions of medical expansion at the societal level (medical investment, medical professionalization/specialization, and an expanded pharmaceutical industry) negatively affect individual subjective health. These findings are robust to different model specifications. We conclude by discussing possible explanations for the adverse effect of medical expansion on subjective health, and how this effect may be related to other mechanisms through which medicine expands.

A Primary Care-Based Early Childhood Nutrition Intervention: Evaluation of a Pilot Program Serving Low-Income Hispanic Women

Nutrition in early childhood can significantly impact physical and mental health outcomes for children. However, research on broadly defined pre/postnatal nutrition interventions is sparse. The present study is a process and outcome evaluation of a primary care-based nutrition intervention targeting low-income Hispanic women. Pregnant women enrolled in the program were in their first trimester and received services through their 6-month well child check. The program provided vouchers for fruits and vegetables from the local farmers' market, nutrition classes, cooking classes, and lactation counseling. We conducted a prospective study of program participants (n = 32) and a comparable group of women for whom the program was not available (n = 29). Panel survey data measured maternal diet, exercise, stress, depression, social support, infant feeding practices, and demographics. Outcome measures obtained from medical records included pregnancy weight gain, infant weight at 6 and 12 months, and infant development at 9 months. Findings reveal that the program was not associated with infant weights. However, despite similar profiles at baseline, women in the intervention group were more likely than women in the comparison group to have significant improvements in diet, exercise, and depression (p ≤ .05). In addition, participants were more likely to breastfeed (p = .07) and their infants were more likely to pass the ages and stages developmental screen (p = .06) than women in the comparison group. The study was limited by a lack of random assignment and small samples. However, the breadth and size of the effects suggest pre/postnatal nutrition interventions integrated into primary care warrant additional investigation.

Medicalization of global health 4: The universal health coverage campaign and the medicalization of global health

Universal health coverage (UHC) has emerged as the leading and recommended overarching health goal on the post-2015 development agenda, and is promoted with fervour. UHC has the backing of major medical and health institutions, and is designed to provide patients with universal access to needed health services without financial hardship, but is also projected to have 'a transformative effect on poverty, hunger, and disease'. Multiple reports and resolutions support UHC and few offer critical analyses; but among these are concerns with imprecise definitions and the ability to implement UHC at the country level. A medicalization lens enriches these early critiques and identifies concerns that the UHC campaign contributes to the medicalization of global health. UHC conflates health with health care, thus assigning undue importance to (biomedical) health services and downgrading the social and structural determinants of health. There is poor evidence that UHC or health care alone improves population health outcomes, and in fact health care may worsen inequities. UHC is reductionistic because it focuses on preventative and curative actions delivered at the individual level, and ignores the social and political determinants of health and right to health that have been supported by decades of international work and commitments. UHC risks commodifying health care, which threatens the underlying principles of UHC of equity in access and of health care as a collective good.

Why behavioural health promotion endures despite its failure to reduce health inequities

Increasing rates of chronic conditions have resulted in governments targeting health behaviour such as smoking, eating high-fat diets, or physical inactivity known to increase risk for these conditions. In the process, many have become preoccupied with disease prevention policies focused excessively and narrowly on behavioural health-promotion strategies. These aim to improve health status by persuading individuals to change their health behaviour. At the same time, health promotion policy often fails to incorporate an understanding of the social determinants of health, which recognises that health behaviour itself is greatly influenced by peoples' environmental, socioeconomic and cultural settings, and that chronic diseases and health behaviour such as smoking are more prevalent among the socially or economically disadvantaged. We identify several reasons why behavioural forms of health promotion are inadequate for addressing social inequities in health and point to a dilemma that, despite these inadequacies and increasing evidence of the social determinants of health, behavioural approaches and policies have strong appeal to governments. In conclusion, the article promotes strategies addressing social determinants that are likely to reduce health inequities. The article also concludes that evidence alone will not result in health policies aimed at equity and that political values and will, and the pressure of civil society are also crucial.

Rethinking the vulnerability of minority populations in research

The Belmont Report, produced in 1979 by a United States government commission, includes minority populations among its list of vulnerable research participants. In this article, we consider some previous attempts to understand the vulnerability of minorities in research, and then provide our own account. First we examine the question of the representation of minorities in research. Then we argue that the best understanding of minorities, vulnerability, and research will begin with a broad understanding of the risk of individual members of minority groups to poor health outcomes. We offer a typology of vulnerability to help with this task. Finally, we show how researchers should be guided by this broad analysis in the design and execution of their research.

Philosophical inquiry and the goals of nursing: a critical approach for disciplinary knowledge development and action

Philosophical inquiry remains critically important for nursing education, practice, and knowledge development. We propose a 3-level taxonomy of philosophical inquiry to guide nursing curricula and research development. Important background information about philosophy and the development of philosophical methods is given. Then philosophical inquiry is linked to the goals of nursing using our proposed taxonomy: level I-cultivating an attitude of "critical consciousness" related to all nursing situations and actions, level II-analysis and application of philosophical perspectives to nursing problems and level III-generating new knowledge for nursing purposes including new theories of practice and research.

Resolutividade na atenção à saúde da criança: percepção de pais e cuidadores

OBJETIVO: Compreender como ocorre a resolutividade do problema de saúde do filho na visão de pais e cuidadores, a partir dos atributos da atenção primária à saúde. MÉTODOS: Pesquisa qualitativa com abordagem hermenêutico-dialética, envolvendo 16 cuidadores de crianças menores de um ano, atendidas em serviços de pronto atendimento. RESULTADOS: Falta de acesso, ausência de vínculo e coordenação, privação do cuidado integral contribui para não resolutividade, levando a busca por soluções alternativas para resolver os problemas de saúde das crianças. CONCLUSÃO: Na apreensão do estudo observa-se que os serviços de atenção primária não se mostram resolutivos diante dos problemas de saúde das crianças, visto que, os atributos essenciais para efetividade nesse ponto de atenção não estiveram presentes.

Public views about health causation, attributions of responsibility, and inequality

Success in addressing health disparities and their social determinants will require understanding public perceptions of health causation, attributions of responsibility, and potential solutions. To explore these perceptions, the authors conducted 12 focus groups (6 with liberals, 6 conservatives; N = 93 participants) in a large U.S. Northeastern state. Participants communicated highly nuanced views about health causation and disparities, identifying layers of responsibility for health. However, individual behaviors and personal responsibility dominated the discussion and served as a counterargument to the significance of social determinants. Participants also showed limited awareness of the range of policies that could be adopted to address health disparities. As policy initiatives benefit from public support in gaining political traction, the authors suggest research paths and possible communication strategies for scholars and advocates.

Narratives and images used by public communication campaigns addressing social determinants of health and health disparities

Researchers have increasingly focused on how social determinants of health (SDH) influence health outcomes and disparities. They have also explored strategies for raising public awareness and mobilizing support for policies to address SDH, with particular attention to narrative and image-based information. These efforts will need to overcome low public awareness and concern about SDH; few organized campaigns; and limited descriptions of existing message content. To begin addressing these challenges, we analyzed characteristics of 58 narratives and 135 visual images disseminated by two national SDH awareness initiatives: The Robert Wood Johnson Foundation's Commission to Build a Healthier America and the PBS-produced documentary film Unnatural Causes. Certain types of SDH, including income/wealth and one's home and workplace environment, were emphasized more heavily than others. Solutions for addressing SDH often involved combinations of self-driven motivation (such as changes in personal health behaviors) along with externally-driven factors such as government policy related to urban revitilization. Images, especially graphs and charts, drew connections among SDH, health outcomes, and other variables, such as the relationship between mother's education and infant mortality as well as the link between heart disease and education levels within communities. We discuss implications of these findings for raising awareness of SDH and health disparities in the US through narrative and visual means.

Exploring interpretation of complexity and typicality in narratives and statistical images about the social determinants of health

This article explores public responses to narratives and statistical images, predominantly graphs and maps, designed to raise awareness of social determinants of health and health disparities. We focus particular attention on respondents' interpretation of the complexity of health causality and the typicality of the situations described. We conducted 24 focus groups with liberal and conservative adults (n = 180 participants) living in a large U.S. northeastern state. Although some narratives showed potential for communicating the complex causality connecting social determinants of health (SDH) to health outcomes, contextual details sometimes disrupted generalization to a broader thematic message. Statistical images often prompted useful speculation about how the factors portrayed might be related, but tended to be regarded with suspicion and criticized for oversimplifying what were perceived to be extremely complex issues. These findings lend theoretical insight to narrative and visual persuasion in the context of social issues with complex causation. We discuss practical implications for those seeking to communicate about the social determinants of health.

Chronic disease and the shifting focus of public health: is prevention still a political lightweight?

Why is it so politically difficult to obtain government investment in public health initiatives that are aimed at addressing chronic disease? This article examines the structural disadvantage faced by those who advocate for public health policies and practices to reduce chronic disease related to people's unhealthy lifestyles and physical environments. It identifies common features that make it difficult to establish and maintain initiatives to prevent or reduce costly illness and physical suffering: (1) public health benefits are generally dispersed and delayed; (2) benefactors of public health are generally unknown and taken for granted; (3) the costs of many public health initiatives are concentrated and generate opposition from those who would pay them; and (4) public health often clashes with moral values or social norms. The article concludes by discussing the importance of a new paradigm, "health in all policies," that targets the enormous health and economic burdens associated with chronic conditions and asserts a need for new policies, practices, and participation beyond the confines of traditional public health agencies and services.