Health Inequities and Social Determinants: Key Concepts and Models

Access (health)

The ability to obtain and use health services, information & resources when needed.

Equity (health)

Fair distribution of resources and opportunities according to need, so groups facing greater barriers receive greater support.

Specific population

A group sharing characteristics, needs or risk factors that shape distinctive health needs (e.g. rural/remote, First Nations, CALD, older people, LGBTQIA+, people in prison).

13 factors creating health inequities

Discrimination; Gender; Access to health care; Unemployment; Social isolation; Dislocation of land; Occupation; Access to and level of education; Geographic location; Racism; Government economic and social policies; Socioeconomic status; Health literacy.

Quantitative measures of health inequity

Numerical, measurable information (e.g. life expectancy, incidence, prevalence, mortality, morbidity, hospitalisation, screening uptake) showing the size and pattern of a health gap.

Qualitative measures of health inequity

Non-numerical information about experiences, perceptions, beliefs and barriers (interviews, focus groups, surveys, case studies) explaining the lived reasons behind a health gap.

Socio-ecological model - 5 levels

Individual, Interpersonal, Organisational, Community, Society.

Socio-ecological model - Individual level

Personal knowledge, attitudes, beliefs, skills, biology and behaviour.

Socio-ecological model - Interpersonal level

Family, friends, peers and close social networks that influence norms, support and behaviour.

Socio-ecological model - Organisational level

Structures, rules and practices within settings such as schools, workplaces, health services and sporting organisations.

Socio-ecological model - Community level

Relationships among organisations, neighbourhoods and local networks; community norms, resources and built environment.

Socio-ecological model - Society level

Broader laws, policies, economic conditions, media, cultural norms and systems.

Social justice principles (3)

Access and equity; Diversity; Supportive environments.

Access & equity (social justice principle)

Remove financial, geographic, cultural, physical or informational barriers and allocate additional support where need is greater.

Diversity (social justice principle)

Recognise differences in culture, language, age, ability, gender, identity and circumstances so difference does not become disadvantage.

Supportive environments (social justice principle)

Create physical, social and policy conditions that make health-promoting choices and service use easier and safer.

Maslow's Hierarchy - 5 levels (bottom to top)

Physiological, Safety, Love and belonging, Esteem, Self-actualisation.

Physiological need (Maslow)

Basic survival needs: food, water, sleep, warmth and other bodily requirements.

Safety need (Maslow)

Security, stability, shelter, protection from harm and access to conditions that preserve health.

Love and belonging need (Maslow)

Relationships, friendship, connection, acceptance and belonging.

Esteem need (Maslow)

Self-respect, competence, confidence, recognition and achievement.

Self-actualisation need (Maslow)

Personal growth, creativity, meaning and reaching one's potential.

PABCAR model - what it stands for

Problem identification; Amenability to change; Benefits and costs; Acceptability; Recommended actions and monitoring.

PABCAR - P (Problem identification)

Define the health issue, who is affected, magnitude, trend and consequences using epidemiological and other evidence.

PABCAR - A (Amenability to change)

Ask whether the problem or its determinants can realistically be modified and whether effective interventions exist.

PABCAR - B/C (Benefits and costs)

Compare expected health, social and economic benefits with financial, workforce, time and opportunity costs.

PABCAR - A (Acceptability)

Assess whether the target population, community, professionals and decision-makers are likely to support and use the measure.

PABCAR - R (Recommended actions and monitoring)

Choose actions, implement them, specify indicators and timeframes, and monitor whether outcomes improve.

Needs assessment - Felt need

What people perceive or say they need.

Needs assessment - Expressed need

A felt need converted into action or demand, such as service use or a waiting list.

Needs assessment - Normative need

Need identified by an expert or professional standard.

Needs assessment - Comparative need

Need inferred by comparing similar populations and finding unequal provision or outcomes.

Needs assessment - 7 steps (in order)

Identify health issues; Analyse the problem; Prioritise issues; Set goals; Determine strategies; Develop action plan; Evaluate outcomes.

Ottawa Charter - Enable

Reduce differences in health status and give people resources/opportunities to achieve their health potential.

Ottawa Charter - Mediate

Coordinate and reconcile different interests across governments, health services, communities, industry and other sectors.

Ottawa Charter - Advocate

Act for political, social, economic or environmental conditions that support health, especially where a group lacks power or resources.

Ottawa Charter - 5 action areas

Build healthy public policy; Create supportive environments; Strengthen community action; Develop personal skills; Reorient health services.

Rio Declaration - 5 actions for social and health equity

Monitor progress and increase accountability.

Adopt better governance for health and development

Promote participation in policy-making and implementation

Strengthen global governance and collaboration

Further reorient the health sector toward reducing health inequities

Private Health Insurance Rebate

A government contribution toward eligible private health insurance premiums, intended to encourage private cover and share demand between private and public services.

Public screening and vaccination programs (healthcare reform)

Organised, publicly supported programs that reduce cost and awareness barriers, increase early detection or immunity and improve population coverage.

Pharmaceutical Benefits Scheme (PBS)

The Australian Government subsidises listed prescription medicines so patients pay a subsidised amount rather than the full market cost.

Health literacy

The ability to find, understand and use health information and services.

Health literacy to health status pathway

Low health literacy leads to difficulty understanding risk/instructions/pathways, delayed care, incorrect medicine use, lower screening, poorer disease control, and poorer health status.

Self-management skill - Assertiveness

Clear, confident and respectful communication of needs, rights and boundaries.

Self-management skill - Stress management

Strategies that reduce the physical, emotional and behavioural effects of stress (e.g. planning, relaxation, sleep, social support, problem solving).

Self-management skill - Resilience

Capacity to adapt, recover and continue functioning after adversity.

Policy vs regulation

A policy is a guiding course of action/strategy; a regulation is a legally enforceable rule made under government authority.

Proscriptive norm

A rule/expectation against a behaviour ('you shouldn't') - e.g. do not drink and drive.

Prescriptive norm

A rule/expectation in favour of a behaviour ('you should') - e.g. wear a seatbelt.

Popular norm

Perceptions or observations of what most people actually do.

Social determinants of health inequities

Social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, transport, culture.

Environmental determinants of health inequities

Features of the natural and built environment; geographical location.

Socioeconomic determinants of health inequities

Education, employment, income, family, housing/neighbourhood, access to services, migration/refugee status, food security.

Biomedical determinants of health inequities

Birth weight, body weight.

Social gradient

Health generally improves at each step up the social hierarchy.

Global/local barrier - Poverty

Insufficient resources restrict food, housing, education, transport and healthcare; poor health can then reduce capacity to work/study, reinforcing poverty.

Global/local barrier - Disease outbreaks

Increase morbidity/mortality, strain health services, disrupt work/school and divert resources from routine care.

Global/local barrier - Famine

Extreme food shortage causing acute malnutrition, increased disease susceptibility, migration and long-term developmental effects.

Global/local barrier - Drought

Reduces water availability and agricultural production, threatening food security and livelihoods.

Global/local barrier - Clean drinking water

Unsafe/unavailable water increases infectious disease risk and time spent collecting water, reducing school/work participation.

WHO role - Provide leadership

Identify urgent global health priorities, coordinate international responses and bring governments, agencies and experts together for joint action.

WHO role - Shape the research agenda

Identify evidence gaps, set research priorities and stimulate generation, translation and sharing of useful health knowledge.

WHO role - Set norms and standards

Develop internationally applicable guidelines, classifications, definitions, treatment recommendations and safety standards.

WHO role - Articulate ethical and evidence-based policy options

Review research and ethics, weigh benefits/harms/equity/feasibility, and present credible policy choices to Member States.

WHO role - Provide technical support

Supply specialist advice, tools, training and resources; help countries implement programs; build workforce/institutional capacity.

WHO role - Monitor the health situation and assessing health trends

Collect, standardise, analyse and publish health data; track outbreaks, risks, inequities and progress.

Australia's 5 gender equality strategic priorities

End sexual and gender-based violence and advance/protect women's sexual and reproductive health and rights; pursue gender-responsive peace and security; deliver gender-equitable climate action and humanitarian assistance; promote women's economic equality and inclusive trade; support locally led approaches to women's leadership.

SDG 2 (verbatim purpose)

End hunger, achieve food security and improved nutrition and promote sustainable agriculture.

SDG 3 (verbatim purpose)

Ensure healthy lives and promote well-being for all at all ages.

SDG 4 (verbatim purpose)

Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.

SDG 5 (verbatim purpose)

Achieve gender equality and empower all women and girls.

SDG 6 (verbatim purpose)

Ensure availability and sustainable management of water and sanitation for all.

Advocacy strategy - Lobbying

Directly communicate with a decision-maker to request a specific change.

Advocacy strategy - Raising awareness

Increase knowledge and visibility of an issue so people recognise its importance.

Advocacy strategy - Creating debate

Place the issue into public or political discussion, often by challenging assumptions or presenting competing evidence.

Advocacy strategy - Developing partnerships

Build relationships between organisations/sectors that contribute expertise, legitimacy, reach or resources.

Advocacy strategy - Building capacity

Strengthen a group's skills, knowledge, resources and structures so it can act/advocate more effectively over time.

Advocacy strategy - Mobilising groups

Organise people to take collective action, demonstrating support and increasing pressure or visibility.

Advocacy strategy - Framing issues

Present the same issue through a strategically chosen lens (equity, cost, rights, safety, productivity) to make it meaningful to the audience.

Advocacy strategy - Using champions

Use credible or influential individuals to attract attention, build trust and amplify a message.

Advocacy strategy - Influencing policy

Seek formal change to rules, funding, institutional practice or government policy so benefits reach a population at scale.

NSFCC - 8 principles

Equity; Collaboration and partnerships; Access; Evidence-based; Person-centred approaches; Sustainability; Accountability and transparency; Shared responsibility.

NSFCC - 3 objectives

Focus on prevention for a healthier Australia; provide efficient, effective and appropriate care to optimise quality of life for people with chronic conditions; target priority populations.

Life expectancy

The average number of years a person is expected to live under current mortality patterns.

Mortality

The frequency of death in a population, including general or cause-specific rates (e.g. infant/maternal mortality).

Morbidity

Illness, disease or disability in a population.

World events & identity - Displacement from traditional homelands

Can sever connection to place/Country, family networks, language, cultural practice and livelihood.

World events & identity - War & conflict

Can cause trauma, bereavement, disrupted education, family separation, migration, poverty and breakdown of institutions.

World events & identity - Violence

Exposure can alter sense of safety, trust and self-concept and increase risk of injury and trauma-related mental health problems.

World events & identity - Natural disasters

Loss of home, community infrastructure and livelihoods can disrupt social roles and place-based identity.

Communication skill - Mediation

A neutral third party facilitates communication so the parties reach their own voluntary agreement (the parties decide).

Communication skill - Negotiation

The parties communicate directly to reach a mutually acceptable outcome (the parties decide).

Communication skill - Compromise

Each party concedes part of its preferred outcome to reach agreement (the parties decide).

Communication skill - Arbitration

A neutral third party considers the dispute and makes a decision, often binding (the arbitrator decides).

Communication skill - Facilitation

Guide a group process so participants can contribute and reach an outcome, without the facilitator deciding the content (the group decides).

Health inquiry - 5 steps

Plan (identify issue + focus questions); Select sources; Interpret (trends/patterns); Build an argument; Present for audience.