Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia.
School of Regulation and Global Governance (RegNet), College of Asia and the Pacific, Australian National University, Canberra, Australia.
Int J Health Policy Manag. 2018 Feb 1;7(2):101-111. doi: 10.15171/ijhpm.2017.130.
Despite decades of evidence gathering and calls for action, few countries have systematically attenuated health inequities (HI) through action on the social determinants of health (SDH). This is at least partly because doing so presents a significant political and policy challenge. This paper explores this challenge through a review of the empirical literature, asking: what factors have enabled and constrained the inclusion of the social determinants of health inequities (SDHI) in government policy agendas?
A narrative review method was adopted involving three steps: first, drawing upon political science theories on agenda-setting, an integrated theoretical framework was developed to guide the review; second, a systematic search of scholarly databases for relevant literature; and third, qualitative analysis of the data and thematic synthesis of the results. Studies were included if they were empirical, met specified quality criteria, and identified factors that enabled or constrained the inclusion of the SDHI in government policy agendas.
A total of 48 studies were included in the final synthesis, with studies spanning a number of country-contexts and jurisdictional settings, and employing a diversity of theoretical frameworks. Influential factors included the ways in which the SDHI were framed in public, media and political discourse; emerging data and evidence describing health inequalities; limited supporting evidence and misalignment of proposed solutions with existing policy and institutional arrangements; institutionalised norms and ideologies (ie, belief systems) that are antithetical to a SDH approach including neoliberalism, the medicalisation of health and racism; civil society mobilization; leadership; and changes in government.
A complex set of interrelated, context-dependent and dynamic factors influence the inclusion or neglect of the SDHI in government policy agendas. It is better to think about these factors as increasing (or decreasing) the 'probability' of health equity reaching a government agenda, rather than in terms of 'necessity' or 'sufficiency.' Understanding these factors may help advocates develop strategies for generating political priority for attenuating HI in the future.
尽管几十年来一直在收集证据并呼吁采取行动，但很少有国家通过针对健康决定因素的行动系统地减少健康不平等现象。这至少部分是因为这样做带来了重大的政治和政策挑战。本文通过对实证文献的回顾来探讨这一挑战，提出以下问题：哪些因素促进和制约了将健康不平等的社会决定因素纳入政府政策议程？
采用叙述性综述方法，分三个步骤进行：首先，借鉴政治科学关于议程设置的理论，制定一个综合理论框架来指导综述；其次，系统地在学术数据库中搜索相关文献；最后，对数据进行定性分析，并对结果进行主题综合。如果研究是实证的，符合规定的质量标准，并确定了促进或制约将健康不平等的社会决定因素纳入政府政策议程的因素，则将其纳入最终综合分析。
最终综合分析共纳入 48 项研究，这些研究涵盖了多个国家背景和司法管辖区，并采用了多种理论框架。有影响力的因素包括在公共、媒体和政治话语中对健康不平等的社会决定因素的框架方式；描述健康不平等的新兴数据和证据；有限的支持证据以及拟议解决方案与现有政策和体制安排的不匹配；与健康决定因素方法背道而驰的制度化规范和意识形态（即信仰体系），包括新自由主义、健康的医学化和种族主义；民间社会动员；领导力；以及政府的变化。
一系列相互关联、依赖背景和动态的因素影响着健康不平等的社会决定因素在政府政策议程中的纳入或忽视。最好将这些因素视为增加（或减少）健康公平进入政府议程的“可能性”，而不是从“必要性”或“充分性”的角度来考虑。了解这些因素可能有助于倡导者制定未来为减少健康不平等现象创造政治优先事项的策略。
