Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Social determinants of mental health in Italy: the role of education in the comparison of migrant and Italian residents.

Mental health is impacted by social, economic, and environmental factors, the Social Determinants of Health (SDH). Migrants experiencing precarious living and working conditions may be more at risk of poor mental health than the majority population.This paper aims to evaluate the relationship of educational attainment and other SDH with depressive symptoms among the resident population, including Italians and migrants.This study examined the respondents to the Italian "Progressi delle Aziende Sanitarie per la Salute in Italia" (PASSI) surveillance system, 2014-18. The sample of 144.055 respondents is composed of the resident working adults aged 25-69 with Italian citizenship (n = 136.514) and foreign citizenship (n = 7.491).Findings show that among Italians high level of education appears to be a protective factor for mental health, in accordance with the international evidence (adjPR: tertiary education 0,74 p-value = 0.000). However, among immigrants high level of education is associated with the presence of depressive symptoms (adjPR: tertiary education: 1.61 p-value = 0.006), particularly for men (adjPR: tertiary education: 2.40 p-value = 0.006). The longer the length of stay in Italy for immigrants the higher the risk of depressive symptoms: adjPR for 10+ years: 2.23 p-value = 0.005.The data show that high education could represent a risk factor for mental health of immigrants. Moreover, among migrants there are some significant mental health inequities between male and female related to the duration of stay in Italy, economic activity and educational level.Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services.

Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis.

BACKGROUND: Poor social circumstances can induce, exacerbate and prolong symptoms of mental health conditions, while having a mental health condition can also lead to worse social outcomes. Many people with mental health conditions prioritise improvement in social and functional outcomes over reduction in clinical symptoms. Interventions that improve social circumstances in this population should thus be considered a priority for research and policy. METHODS: This rapid evidence synthesis reports on randomised controlled trials of interventions to improve social circumstances across eight social domains (Housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship) in people with mental health conditions. Economic evaluations were also identified. A comprehensive, stepped search approach of the Cochrane library, MEDLINE, Embase, PsycINFO, Web of Science and Scopus was conducted. RESULTS: One systematic review and 102 randomised controlled trials were included. We did not find RCT evidence for interventions to improve family, intimate and caring relationships and only one or two trials for each of improving money and basic needs, victimisation and exploitation, and rights, inclusion and citizenship. Evidence from successful interventions in improving homelessness (Housing First) and employment (Individual Placement and Support) suggests that high-intensity interventions which focus on the desired social outcome and provide comprehensive multidisciplinary support could influence positive change in social circumstances of people with mental health conditions. Objective social isolation could be improved using a range of approaches such as supported socialisation and social skills training but interventions to reduce offending showed few benefits. Studies with cost and cost-effectiveness components were generally supportive of interventions to improve housing and vocational outcomes. More research is needed to ensure that social circumstances accompanied by high risks of further exacerbation of mental health conditions are adequately addressed. CONCLUSIONS: Although there is a large body of literature examining how to support some aspects of life for people with mental health conditions, more high-quality evidence is required in other social domains. Integration into mental health services of interventions targeting social circumstances could significantly improve a number of social outcomes.

Inequalities in excess premature mortality in England during the COVID-19 pandemic: a cross-sectional analysis of cumulative excess mortality by area deprivation and ethnicity.

OBJECTIVES: To examine magnitude of the impact of the COVID-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity. DESIGN: A statistical model to estimate increased mortality in population subgroups during the COVID-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous 5 years. SETTING: Information on deaths registered in England since 2015 was used, including age, sex, area of residence and cause of death. Ethnicity was obtained from Hospital Episode Statistics records linked to death data. PARTICIPANTS: Population study of England, including all 569 824 deaths from all causes registered between 21 March 2020 and 26 February 2021. MAIN OUTCOME MEASURES: Excess mortality in each subgroup over and above the number expected based on trends in mortality in that group over the previous 5 years. RESULTS: The gradient in excess mortality by area deprivation was greater in the under 75s (the most deprived areas had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the black and Asian groups, all area deprivation quintiles had significantly larger excesses than white groups in the most deprived quintiles and there were no clear gradients across quintiles. Among the white group, only those in the most deprived quintile had more excess deaths than deaths directly involving COVID-19. CONCLUSION: The COVID-19 pandemic has widened inequalities in premature mortality by area deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of area deprivation, and the white group the most deprived areas. Statistics limited to deaths directly involving COVID-19 understate the pandemic's impact on inequalities by area deprivation and ethnic group at younger ages.

Ethnicity, household composition and COVID-19 mortality: a national linked data study.

OBJECTIVE: To estimate the proportion of ethnic inequalities explained by living in a multi-generational household. DESIGN: Causal mediation analysis. SETTING: Retrospective data from the 2011 Census linked to Hospital Episode Statistics (2017-2019) and death registration data (up to 30 November 2020). PARTICIPANTS: Adults aged 65 years or over living in private households in England from 2 March 2020 until 30 November 2020 (n=10,078,568). MAIN OUTCOME MEASURES: Hazard ratios were estimated for COVID-19 death for people living in a multi-generational household compared with people living with another older adult, adjusting for geographic factors, socioeconomic characteristics and pre-pandemic health. RESULTS: Living in a multi-generational household was associated with an increased risk of COVID-19 death. After adjusting for confounding factors, the hazard ratios for living in a multi-generational household with dependent children were 1.17 (95% confidence interval [CI] 1.06-1.30) and 1.21 (95% CI 1.06-1.38) for elderly men and women. The hazard ratios for living in a multi-generational household without dependent children were 1.07 (95% CI 1.01-1.13) for elderly men and 1.17 (95% CI 1.07-1.25) for elderly women. Living in a multi-generational household explained about 11% of the elevated risk of COVID-19 death among elderly women from South Asian background, but very little for South Asian men or people in other ethnic minority groups. CONCLUSION: Elderly adults living with younger people are at increased risk of COVID-19 mortality, and this is a contributing factor to the excess risk experienced by older South Asian women compared to White women. Relevant public health interventions should be directed at communities where such multi-generational households are highly prevalent.

Global action on the social determinants of health.

Action on the social determinants of health (SDH) is required to reduce inequities in health. This article summarises global progress, largely in terms of commitments and strategies. It is clear that there is widespread support for a SDH approach across the world, from global political commitment to within country action. Inequities in the conditions in which people are born, live, work and age, are however driven by inequities in power, money and resources. Political, economic and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to a focus solely on increasing productivity. A health in all policies approach can go some way to ensure this consideration, and we present evidence that some countries are taking this approach, however given entrenched inequalities, there is some way to go. Measuring progress on the SDH globally will be key to future development of successful policies and implementation plans, enabling the identification and sharing of best practice. WHO work to align measures with the sustainable development goals will help to forward progress measurement.

Interventions to reduce inequalities in health and early child development in Europe from a qualitative perspective.

BACKGROUND: Early childhood is a critical stage of development. Inequalities in experiences affect children's wellbeing and determine their development. Early years interventions focusing on children and their parents may help address inequalities during this critical period. Understanding the experiences and perceptions of parents receiving early years programmes and staff providing these may help service development and delivery. The objective of this study was to describe staff and parents' accounts of how early childhood programmes in different European country contexts improved child development. METHODS: Five early years programmes were selected using pre-set criteria out of ten proposed ones. Twenty-five individual interviews and six focus groups were carried out with staff running interventions and with users, children and their families in different EU countries. Investigations of the studies were carried out using qualitative research methods. Data were collected by collaborating partner institutions included in the project. RESULTS: Participants described programmes which aimed to provide activities to stimulate children's learning through structured play and which provided support and assistance for parents. In these, parents were actively involved in activities. Parents and staff referred to establishing long-term trust based relationships as a key element for programmes to improve parents' self-esteem and reduce their stress levels which in turn helped improve their children's development. CONCLUSIONS: Programmes described by staff as being successful, delivered services tailored to parents and their children. Adapting to and understanding the families' circumstances and involving parents was seen by staff as important. Staff also described establishing trust based relationships as a key enabler in programme delivery; their perceptions were that parents should be empowered to develop their own capacities thus strengthening their abilities to assist in their children's learning, which had a positive effect on children.

Moving forward monitoring of the social determinants of health in a country: lessons from England 5 years after the Marmot Review.

BACKGROUND: England has a long history of government-commissioned reviews of national inequalities. The latest review, the Marmot Review, was commissioned by a government headed by the same party (the Labour Party) that had introduced the National Health Service in 1948, but the review was implemented by a coalition of different parties (Conservatives and Liberal Democrats). At the same time, a government reform of health services took place, and the monitoring of the existing inequality strategy was changed. OBJECTIVES: This paper examines the lessons that can be learned about indicators for monitoring social determinants of health inequalities from the Marmot Review and recent health inequality strategies in England. DESIGN: The paper provides a narrative review of key findings on the collection, presentation, and analysis of routine data in England in the past 5 years, comparing what has been learned from the Marmot Review and other evaluations of the first health inequality strategy in England. RESULTS: The emphasis on monitoring has progressively shifted from monitoring a small number of targets and supporting information to frameworks that monitor across a wide range of determinants of both the causes of ill-health and of health service performance. As these frameworks become ever larger, some consideration is being given to the key indicators. CONCLUSIONS: Although the frameworks used in England for monitoring health inequality strategies have developed considerably since the first strategy began, lessons continue to be learned about how monitoring could be improved. Many of these are applicable to countries initiating or reviewing their strategies.

How a universal health system reduces inequalities: lessons from England.

BACKGROUND: Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period. METHODS: Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare. RESULTS: Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare. CONCLUSIONS: Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.

How Can a Global Social Support System Hope to Achieve Fairer Competiveness? Comment on "A Global Social Support System: What the International Community Could Learn From the United States' National Basketball Association".

Ooms et al sets out some good general principles for a global social support system to improve fairer global competitiveness as a result of redistribution. This commentary sets out to summarize some of the conditions that would need to be satisfied for it to level up gradients in inequality through such a social support system, using the National Basketball Association (NBA) example as a point of reference. From this, the minimal conditions are described that would be required for the support system, proposed in the article by Ooms et al, to succeed.

Systematic review of parenting interventions in European countries aiming to reduce social inequalities in children's health and development.

BACKGROUND: Early child development influences many aspects of wellbeing, health, competence in literacy and numeracy, criminality, and social and economic participation throughout the life course. Children from disadvantaged groups have less possibilities of achieving full development. By providing a positive start for all children across the social gradient, improved developmental outcomes will be seen during later childhood and throughout their lives. The objective of this systematic review was to identify interventions during early childhood in countries from the World Health Organisation European Region in 1999-2013 which reduced inequalities in children's health and development. METHODS: A systematic review was carried out adhering to the PRISMA guidelines. The review examined universal, targeted and proportionate universalism interventions, programs and services using an electronic search strategy in PubMed and the International Bibliography of the Social Sciences [IBSS] databases. A further search was performed in the grey literature. Interventions were included only if they were aimed at children or their parents and had been evaluated. RESULTS: We identified 23 interventions in total: 6 in the PubMed data base, 5 in IBSS and 12 in grey literature. All but 1 intervention-delivered in Sweden-were carried out in the United Kingdom and the Republic of Ireland. These aimed to improve parenting abilities, however, some had additional components such as: day-care provision, improving housing conditions and speech or psychological therapies. Programmes offering intensive support, information and home visits using a psycho-educational approach and aimed at developing parent's and children's skills showed more favourable outcomes. These were parenting behaviours, overall children's health and higher level of fine motor skills and cognitive functioning. Child injuries and abuse were also reduced. Two interventions were universally proportionate and all others were aimed at a specific target population. CONCLUSIONS: Interventions with better outcomes and a higher level of evidence combined workshops and educational programmes for both parents and children beginning during early pregnancy and included home visits by specialised staff. Further evaluation and publication of early years interventions should be carried out also within a wider range of countries than just the UK and Ireland.

Social inequalities in early childhood health and development: a European-wide systematic review.

The evidence examining the relationship between specific social factors and early childhood health and developmental outcomes has never been systematically collated or synthesized. This review aims to identify the key social factors operating at the household, neighborhood, and country levels that drive inequalities in child health and development. Medline and CHICOS (a European child-cohort inventory) were systematically searched to identify all European studies published within the past 10 y. 13,270 Medline articles and 77 European child cohorts were searched, identifying 201 studies from 32 European countries. Neighborhood deprivation, lower parental income/wealth, educational attainment, and occupational social class, higher parental job strain, parental unemployment, lack of housing tenure, and household material deprivation were identified as the key social factors associated with a wide range of adverse child health and developmental outcomes. Similar association trends were observed across most European countries, with only minor country-level differences. Multiple adverse social factors operating at both the household and neighborhood levels are independently associated with a range of adverse health and developmental outcomes throughout early childhood. The social gradient in health and developmental outcomes observed throughout the remaining life course may be partly explained by gradients initiated in early childhood.

Association of socioeconomic position with smoking and mortality: the contribution of early life circumstances in the 1946 birth cohort.

BACKGROUND: A large part of the socioeconomic mortality gradient can be statistically accounted for by social patterning of adult health behaviours. However, this statistical explanation does not consider the early life origins of unhealthy behaviours and increased mortality risk. METHODS: Analysis is based on 2132 members of the MRC National Survey of Health and Development with mortality follow-up and complete data. Smoking behaviour was summarised by pack-years of exposure. Socioeconomic circumstances were measured in childhood (father's social class (age 4), maternal education (age 6)) and age 26 (education attainment, home ownership, head of household social class). We estimated the direct effect of early circumstances, the indirect effect through smoking and the independent direct effect of smoking on inequality in all-cause mortality from age 26 to 66. RESULTS: Mortality risk was higher in those with lower socioeconomic position at age 26, with a sex-adjusted HR (relative index of inequality) of 1.97 (95% CI 1.18 to 3.28). Smoking and early life socioeconomic indicators together explained 74% of the socioeconomic gradient in mortality (the gradient). Early life circumstances explained 47% of the gradient, 23.5% directly and 23.0% indirectly through smoking. The explanatory power of smoking behaviour for the gradient was reduced from 50.8% to 28% when early life circumstances were added to the model. CONCLUSIONS: Early life socioeconomic circumstances contributed importantly to social inequality in adult mortality. Our life-course model focusing on smoking provides evidence that social inequalities in health will persist unless prevention strategies tackle the intergenerational transmission of disadvantage and risk.

WHO European review of social determinants of health and the health divide.

The European region has seen remarkable heath gains in those populations that have experienced progressive improvements in the conditions in which people are born, grow, live, and work. However, inequities, both between and within countries, persist. The review reported here, of inequities in health between and within countries across the 53 Member States of the WHO European region, was commissioned to support the development of the new health policy framework for Europe: Health 2020. Much more is understood now about the extent, and social causes, of these inequities, particularly since the publication in 2008 of the report of the Commission on Social Determinants of Health. The European review builds on the global evidence and recommends policies to ensure that progress can be made in reducing health inequities and the health divide across all countries, including those with low incomes. Action is needed--on the social determinants of health, across the life course, and in wider social and economic spheres--to achieve greater health equity and protect future generations.

Building of the global movement for health equity: from Santiago to Rio and beyond.

Health inequalities are present throughout the world, both within and between countries. The Commission on Social Determinants of Health drew attention to dramatic social gradients in health within most countries and made proposals for action. These inequalities are not inevitable. The purpose of this article is to report on activity that has taken place worldwide after the report by the Commission on Social Determinants of Health. First, we summarise the global situation. Second, we summarise an interim report of the emerging findings from an independent review of social determinants and the health divide, which was commissioned by the WHO European region. The world conference on social determinants of health will be held in Rio de Janeiro, Brazil, in October, 2011. This summit provides an opportunity to galvanise support, prioritise action, and respond to the call by the Commission on Social Determinants of Health for social justice as a route to a fair distribution of health.