Pathways of influence on equity in health

doi:10.1016/j.socscimed.2006.11.027

Social Science & Medicine

Volume 64, Issue 7, April 2007, Pages 1355-1362

https://doi.org/10.1016/j.socscimed.2006.11.027 Get rights and content

Abstract

An increasing number of studies are documenting the existence of inequities, and attention is now turning to exploring pathways through which they are generated and might be attacked. This appears to be an opportune time to consider what has been learned and what future directions might be taken by researchers to fill gaps in knowledge and make research more useful for policy interventions.

This commentary briefly reviews some of the main contributions of past research that have possible relevance to pathways, considers what those pathways might include, and concludes with implications for future research. It makes the case for a conceptualization of influences on equity that explicitly includes distribution of health as an outcome as well as characteristics of the society as influences.

Section snippets

Contributions of the literature to knowledge about the genesis of inequity in health

Recent definitions of equity in health characterize it as the absence of systematic and potentially remediable differences in one or more aspects of health between groups of people characterized socially, geographically, or demographically (International Society for Equity in Health, undated).¹ This conceptualization

Possible pathways of influences on equity in health

These research findings suggest possible pathways of effect. Variability according to measure of health provides the basis for postulating that pathways differ depending on the health goal. Inequities in case fatality suggest relatively greater salience of health services whereas inequities in incidence lend relatively greater weight to social factors (including life course influences). Inequities in prevalence, in death rates, and in life expectancy reflect both the occurrence as well as the

Implications for future research

(1)
Almost all studies focus on average (area-wide) health, e.g., overall rates of infant mortality, and, therefore, do not provide information on equity in (distributions of) health. Systematic differences in overall health levels across countries reflect inter-country differences, but neither they nor within-country studies examine the impact of societal factors on distribution of health within countries. The development of mapping technology could enhance the availability of data on

Implications for future research and development of interventions

In view of the likely importance of many societal influences and the relative dearth of studies examining their relative influence on distributions of health, a more concerted approach to identifying and measuring a minimum core set including the most salient policy, economic, and environmental characteristics, seems warranted. Cultural characteristics and ingrained behaviors undoubtedly play a role also, at least in particular countries (Cooper, Ordunez, Iraola, Munoz, & Espinosa-Brito, 2006;

References (53)

A.E. Birn
Gates's grandest challenge: Transcending technology as public health ideology
Lancet
(2005)
A.V. Diez-Roux et al.
A multilevel analysis of income inequality and cardiovascular disease risk factors
Social Science & Medicine
(2000)
I. Kawachi et al.
Women's status and the health of women and men: A view from the States
Social Science & Medicine
(1999)
J.A. Macinko et al.
Wage inequality, the health system, and infant mortality in wealthy industrialized countries, 1970–1996
Social Science & Medicine
(2004)
V. Navarro et al.
The political context of social inequalities and health
Social Science & Medicine
(2001)
A. Oliver et al.
Addressing health inequalities
Lancet
(2002)
D. Raphael et al.
The welfare state as a determinant of women's health: Support for women's quality of life in Canada and four comparison nations
Health Policy
(2004)
P.B. Reagan et al.
Race and ethnic differences in determinants of preterm birth in the USA: Broadening the social context
Social Science & Medicine
(2005)
B. Starfield et al.
Policy relevant determinants of health: An international perspective
Health Policy
(2002)
C.G. Victora et al.
Explaining trends in inequities: Evidence from Brazilian child health studies
Lancet
(2000)

R.G. Wilkinson et al.

Income inequality and population health: A review and explanation of the evidence

Social Science & Medicine

(2006)

P. Braveman

Health disparities and health equity: Concepts and measurement

Annual Review of Public Health

(2006)

Chapman, K., (2006). Using social transfers to scale up equitable access to education and health services. Background...

J. Cohen

Global health. The new world of global health

Science

(2006)

R.S. Cooper

Social inequality, ethnicity and cardiovascular disease

International Journal of Epidemiology

(2001)

R.S. Cooper et al.

Cardiovascular disease and associated risk factors in Cuba: Prospects for prevention and control

American Journal of Public Health

(2006)

Cutler, D., Deaton, A., & Lleras-Muney, A. (2005). The Determinants of Mortality. Princeton, NJ, and Cambridge, MA:...

D.M. Cutler et al.

Is technological change in medicine worth it?

Health Affairs

(2001)

S. Declich et al.

Public health surveillance: Historical origins, methods and evaluation

Bulletin of the World Health Organization

(1994)

V. Etches et al.

Measuring population health: A review of indicators

Annual Review of Public Health

(2006)

R.G. Evans et al.

Consuming research, producing policy?

American Journal of Public Health

(2003)

M. Exworthy et al.

Evidence into policy and practice? Measuring the progress of US and UK policies to tackle disparities and inequalities in US and UK health and health care

Milbank Quarterly

(2006)

A. Franco et al.

Effect of democracy on health: Ecological study

British Medical Journal

(2004)

H. Graham

Tackling inequalities in health in England: Remedying health disadvantages, narrowing health gaps or reducing health gradients?

Journal of Social Policy

(2004)

T.A. Houweling et al.

Determinants of under-5 mortality among the poor and the rich: A cross-national analysis of 43 developing countries

International Journal of Epidemiology

(2005)

International Society for Equity in Health. 〈www.iseqh.org〉 (accessed March...

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CommentaryPathways of influence on equity in health

Abstract

Section snippets

Contributions of the literature to knowledge about the genesis of inequity in health

Possible pathways of influences on equity in health

Implications for future research

Implications for future research and development of interventions

Lancet

Social Science & Medicine

Social Science & Medicine

Social Science & Medicine

Social Science & Medicine

Lancet

Health Policy

Social Science & Medicine

Health Policy

Lancet

Social Science & Medicine

Health disparities and health equity: Concepts and measurement

Annual Review of Public Health

Global health. The new world of global health

Science

Social inequality, ethnicity and cardiovascular disease

International Journal of Epidemiology

Cardiovascular disease and associated risk factors in Cuba: Prospects for prevention and control

American Journal of Public Health

Is technological change in medicine worth it?

Health Affairs

Public health surveillance: Historical origins, methods and evaluation

Bulletin of the World Health Organization

Measuring population health: A review of indicators

Annual Review of Public Health

Consuming research, producing policy?

American Journal of Public Health

Evidence into policy and practice? Measuring the progress of US and UK policies to tackle disparities and inequalities in US and UK health and health care

Milbank Quarterly

Effect of democracy on health: Ecological study

British Medical Journal

Tackling inequalities in health in England: Remedying health disadvantages, narrowing health gaps or reducing health gradients?

Journal of Social Policy

Determinants of under-5 mortality among the poor and the rich: A cross-national analysis of 43 developing countries

International Journal of Epidemiology

Commentary
Pathways of influence on equity in health