Freudenberg Nicholas, Franzosa Emily, Chisholm Janice, Libman Kimberly
City University of New York, NY, USA
City University of New York, NY, USA.
Health Educ Behav. 2015 Apr;42(1 Suppl):46S-56S. doi: 10.1177/1090198114568304.
Growing evidence shows that unequal distribution of wealth and power across race, class, and gender produces the differences in living conditions that are "upstream" drivers of health inequalities. Health educators and other public health professionals, however, still develop interventions that focus mainly on "downstream" behavioral risks. Three factors explain the difficulty in translating this knowledge into practice. First, in their allegiance to the status quo, powerful elites often resist upstream policies and programs that redistribute wealth and power. Second, public health practice is often grounded in dominant biomedical and behavioral paradigms, and health departments also face legal and political limits on expanding their scope of activities. Finally, the evidence for the impact of upstream interventions is limited, in part because methodologies for evaluating upstream interventions are less developed. To illustrate strategies to overcome these obstacles, we profile recent campaigns in the United States to enact living wages, prevent mortgage foreclosures, and reduce exposure to air pollution. We then examine how health educators working in state and local health departments can transform their practice to contribute to campaigns that reallocate the wealth and power that shape the living conditions that determine health and health inequalities. We also consider health educators' role in producing the evidence that can guide transformative expansion of upstream interventions to reduce health inequalities.
越来越多的证据表明，财富和权力在种族、阶级和性别间的不平等分配造成了生活条件的差异，而这些差异是健康不平等的“上游”驱动因素。然而，健康教育工作者和其他公共卫生专业人员仍主要围绕“下游”行为风险制定干预措施。有三个因素可以解释将这一认识转化为实践的困难。其一，强大的精英阶层出于对现状的维护，往往抵制那些重新分配财富和权力的上游政策及项目。其二，公共卫生实践通常基于主流的生物医学和行为范式，而且卫生部门在扩大其活动范围方面还面临法律和政治限制。最后，上游干预措施效果的证据有限，部分原因是评估上游干预措施的方法不够完善。为了说明克服这些障碍的策略，我们介绍了美国近期为制定生活工资、防止房屋止赎以及减少空气污染暴露而开展的运动。接着，我们探讨了在州和地方卫生部门工作的健康教育工作者如何转变其做法，以助力那些重新分配塑造决定健康及健康不平等的生活条件的财富和权力的运动。我们还考虑了健康教育工作者在提供证据方面的作用，这些证据能够指导上游干预措施进行变革性扩展，以减少健康不平等。
