La salud y sus determinantes sociales. Desigualdades y exclusión en la sociedad del siglo XXI
El concepto de salud ha experimentado un proceso de revisión constante. Desde mediados del siglo XX se ha producido un desplazamiento desde la búsqueda de las causas de la enfermedad centradas en el individuo a la aparición de los determinantes sociales, los principales moduladores del fenómeno salud y la enfermedad. Hoy sabemos que la salud y la calidad de vida son un resultado social directamente relacionado con las condiciones generales de la vida de las personas y con la forma de vivir; en este sentido se han hecho notables esfuerzos en las últimas décadas para comprender cómo interactúan los determinantes sociales y se producen los resultados en salud. Analizamos las aportaciones que han conseguido poner de manifiesto los principales factores generadores de las desigualdades sociales incluyendo un análisis de las desigualdades en salud de las mujeres, la vulnerabilidad y el riesgo de exclusión.
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Background: Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature, there is an urgent need for coordination of care.
Objective: The objective of this study was to investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication.
Methods: The design was a controlled before-after study with 12 months follow-up in 11 family practices in the eastern part of the Netherlands. Participants consisted of frail older people living in the community requiring multidisciplinary (long-term) care. The intervention used was the health and welfare portal (ZWIP): an OHC for frail elderly patients, their informal caregivers and professionals. ZWIP contains a secure messaging system supplemented by a shared electronic health record. Primary outcomes were scores on the Instrumental Activities of Daily Living scale (IADL), mental health, and social activity limitations.
Results: There were 290 patients in the intervention group and 392 in the control group. Of these, 76/290 (26.2%) in the intervention group actively used ZWIP. After 12 months follow-up, we observed no significant improvement on primary patient outcomes. ADL improved in the intervention group with a standardized score of 0.21 (P=.27); IADL improved with 0.50 points, P=.64.
Conclusions: Only a small percentage of frail elderly people in the study intensively used ZWIP, our newly developed and innovative eHealth tool. The use of this OHC did not significantly improve patient outcomes. This was most likely due to the limited use of the OHC, and a relatively short follow-up time. Increasing actual use of eHealth intervention seems a precondition for large-scale evaluation, and earlier adoption before frailty develops may improve later use and effectiveness of ZWIP.
Two hundred fifty years of slavery. Ninety years of Jim Crow. Sixty years of separate but equal. Thirty-five years of racist housing policy. Until we reckon with our compounding moral debts, America will never be whole.
Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient’s preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems.
As shared decision makes increasing headway in healthcare policy, it is under more scrutiny. We sought to identify and dispel the most prevalent myths about shared decision making.
In 20 years in the shared decision making field one of the author has repeatedly heard mention of the same barriers to scaling up shared decision making across the healthcare spectrum. We conducted a selective literature review relating to shared decision making to further investigate these commonly perceived barriers and to seek evidence supporting their existence or not.
Beliefs about barriers to scaling up shared decision making represent a wide range of historical, cultural, financial and scientific concerns. We found little evidence to support twelve of the most common beliefs about barriers to scaling up shared decision making, and indeed found evidence to the contrary.
Our selective review of the literature suggests that twelve of the most commonly perceived barriers to scaling up shared decision making across the healthcare spectrum should be termed myths as they can be dispelled by evidence.
Our review confirms that the current debate about shared decision making must not deter policy makers and clinicians from pursuing its scaling up across the healthcare continuum.
Language is important. The call for papers in this supplement was entitled health equity. Yet the call asked for papers that address disparities in health. In the United States, disparities, most often, has been used to refer to racial/ethnic differences in health, or more commonly health care. We note that the call in this supplement expands the focus and highlights differences by socioeconomic status and geographic location, among others. By tradition, in the United Kingdom we have used the term inequalities to describe the differences in health between groups defined on the basis of socioeconomic conditions. To reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviors.
Resources on the Health Literate Care Model. Find health literacy and health information related resources, tools, research and reports.
In order for health outcomes to improve, patients must be fully engaged in prevention, decision making, and self-management. The Health Literate Care Model weaves health literacy principles into the widely adopted Chronic Care Model and calls for health care providers to:
Approach all patients as if they are at risk of not understanding health information.Employ a range of strategies for clear communication.Confirm patients’ understanding.
When a health care organization adopts the Health Literate Care Model, health literacy becomes an organizational value infused into all aspects of planning and operations.
Health Beyond Health Care: Q&A with Matthew Trowbridge, MD, MPH
Through a collaboration between with Terry Huang, who was a program officer at the National Institute of Child Health and Human Development and a leader in that institute’s childhood obesity research portfolio. [Editor’s note: He is now a Professor and Chair of the Department of Health Promotion, Social & Behavioral Health University of Nebraska Medical Center College of Public Health.] Back in 2007, Terry had been thinking about how architecture, and particularly school architecture, could be utilized as a tool for obesity prevention. The thinking behind that is that schools have always been a particularly interesting environment for child health very broadly, but also obesity prevention in particular, partly because children spend so much time at school and because the school day provides an important opportunity to help children develop healthy lifelong attitudes and behaviors.
(Image courtesy: Tom Daly)
One of the insights that Terry had was that while public health had done a lot to develop programming for school-based obesity prevention, the actual school building itself had really not been looked at in terms of opportunities to help make school-based obesity prevention programs work most effectively. In 2007, Terry actually wrote a journal article outlining ideas for ways in which architecture could be used to augment school-based childhood obesity prevention programs that was published in one of the top obesity journals. When I met Terry at NIH, we realized we both shared an interest in moving beyond studying the association between built environment and health toward real world translation. In other words, providing tangible tools and guidelines to foster collaboration between public health and the design community to bring these ideas into action.
This paper examines a CDC initiative aimed at developing a feasible method of engaging the public that would better inform agency or sponsor decision making in the short term and build trust between the agency or sponsor and the public over the longer term. The initiative succeeded in the short term, but no ongoing infrastructure devoted to public engagement was created to achieve similar results over the longer term.
A public engagement initiative was undertaken in 2001 to find ways in which the Centers for Disease Control and Prevention (CDC) could work productively with the public to better inform decision making in the short term and improve trust over the longer term. A new model, renamed the Decision-focused Public Engagement Table (DPET), was developed and used in nine projects between 2005 and 2009. The origins of this initiative, the characteristics of the DPET model, and detailed case abstracts describing the key features and conclusions from each project are described in this paper.
While there was variation in how the model was replicated, its essential features demonstrated that it is feasible and practical to carry out for a variety of difficult decisions involving different agency sponsors. The degree to which public advice influenced decisions was mixed. For some projects the advice was clearly used to shape the decision making, for others it was difficult to isolate the public’s influence from that of other contributors, and for some projects the public input was not seriously considered.
The project evaluations showed an increase in trust, at least in local government, at the time the projects ended, and citizens reported they were more likely to participate in other types of engagement in the future. Taken as a whole, the projects provided “proof of principle” that engaging the public in participatory policy making sponsored by governmental agencies is feasible and can be influential. The initiative also provided clear evidence that citizens make policy choices which are different from those made by experts on the same issue. And, they appear to be better decisions because they are both well-informed and well-aligned with public values and the broader public interest.
Despite the success achieved, the projects did not result in the creation of any permanent infrastructure to support and strengthen public engagement work within the participating agencies. This was disappointing and the reasons are numerous and complex. They are the subject of a companion paper being published in this issue of the Journal which examined the challenges encountered from a broader perspective. It also includes possible approaches to overcome the challenges and embed public engagement as an effective means of addressing the frequent gridlock caused by difficult, values-based public policy decisions.