Keeping It Political and Powerful: Defining the Structural Determinants of Health.

Policy Points The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work-implicitly and explicitly-to maintain their advantage by reinforcing or modifying these rules. This theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health's role in shifting power relations and engaging politically, especially in its policy work. Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.

What Do We Know About the Drivers of Health and Equity? A Narrative Review of Graphic Representations.

Purpose: Frameworks can be influential tools for advancing health and equity, guiding population health researchers and practitioners. We reviewed frameworks with graphic representations that address the drivers of both health and equity. Our purpose was to summarize and discuss graphic representations of population health and equity and their implications for research and practice. Methods: We identified publicly available frameworks that were scholarly or practice oriented and met defined inclusion and exclusion criteria. The identified frameworks were then described and coded based on their primary area of focus, key elements included, and drivers of health and equity specified. Results: The variation in purpose, concepts, drivers, underlying theory or scholarly evidence, and accompanying measures was highlighted. Graphic representations developed over the last 20 years exhibited some consistency in the drivers of health; however, there has been little uniformity in depicting the drivers of equity, disparities or interplay among the determinants of health, or transparency in underlying theories of change. Conclusion: We found that current tools do not offer consistency or conceptual clarity on what shapes health and equity. Some variation is expected as it is difficult for any framework to be all things to all people. However, keeping in mind the importance of audience and purpose, the field of population health research and practice should work toward greater clarity on the drivers of health and equity to better guide critical analysis, narrative development, and strategic actions needed to address structural and systemic issues perpetuating health inequities.