Institute of Child Development, University of Minnesota, 51 E. River Road, Minneapolis, MN 55416, USA.
Department of Pediatrics, Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
Health Promot Int. 2024 Oct 1;39(5). doi: 10.1093/heapro/daae122.
Although the World Health Organization's (WHO's) framework on social and structural determinants of health and health inequities (SSDHHI) has done much to raise awareness of these determinants, it does not go far enough in considerations of politics and power. The framework has become more de-politicized since its publication, with the definition of social determinants shifting toward downstream and individualized factors. In the meantime, new research fields on legal, commercial and political determinants of health and health inequities have emerged; however, these have not become integrated adequately into broader SSDHHI frameworks. To address these challenges, we argue for a re-politicization and an expansion of the WHO's framework by including the agents who have power over shaping structural determinants and the ways they use power to shape these determinants. We also provide a more detailed conceptualization of structural determinants to facilitate research. We propose a guideline for evaluating studies according to the extent to which they point upstream versus downstream and incorporate agents and considerations of power. We then use this framework to encourage more research on associations among agents, mechanisms of power, and structural determinants; how changes in structural determinants affect power dynamics among agents; and a wider focus on structural determinants beyond laws and policies, such as broad economic and sociopolitical systems. We also urge researchers to consider societal and institutional forces shaping their research with respect to SSDHHI. Research based on this framework can be used to provide evidence for advocacy for structural changes and to build more just systems that respect the fundamental human right to a healthy life.
尽管世界卫生组织（WHO）关于社会和结构性决定因素及其对健康和健康不公平的影响的框架（SSDHHI）在提高对这些决定因素的认识方面做了很多工作，但在政治和权力方面的考虑还远远不够。自该框架发布以来，其社会决定因素的定义已经越来越淡化，转向下游和个体化因素。与此同时，关于健康和健康不公平的法律、商业和政治决定因素的新研究领域已经出现；然而，这些因素并没有充分融入更广泛的 SSDHHI 框架中。为了解决这些挑战，我们主张通过纳入对塑造结构性决定因素有权力的行为体以及他们利用权力塑造这些决定因素的方式，重新政治化和扩大世卫组织的框架。我们还提供了对结构性决定因素的更详细概念化，以促进研究。我们提出了一个根据研究指向上游还是下游的程度以及纳入行为体和权力考虑因素来评估研究的准则。然后，我们使用这个框架来鼓励更多地研究行为体之间的关联、权力机制和结构性决定因素；结构性决定因素的变化如何影响行为体之间的权力动态；以及更广泛地关注超越法律和政策的结构性决定因素，例如广泛的经济和社会政治制度。我们还敦促研究人员考虑塑造其 SSDHHI 研究的社会和制度力量。基于该框架的研究可以用于为结构性变革提供证据，并建立更公正的尊重享有健康生活的基本人权的系统。
