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BACKGROUND: The social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions. METHODS: Nine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented. RESULTS: The review found a large (n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations. CONCLUSIONS: The results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review. TRIAL ...

The �new style� occupational health and safety legislation implemented in Australia from the late 1970s changed the character of OHS legal obligations, establishing general duties supported by process, performance and, more rarely, specification standards,1 and extending obligations to those who propagate risks as designers, manufacturers, importers or suppliers � the �upstream duty holders�. This article examines how OHS agencies inspect and enforce OHS legislation upstream, drawing on empirical research in four Australian states and relevant case law. We argue that upstream duty holders are an increasing area of attention for OHS inspectorates but these inspectorates have not yet risen to the challenge of harnessing these parties to help stem, at the source, the flow of risks into workplaces.

Small workplaces have particular injury risks and are enduringly difficult for the occupational health and safety (OHS) system to reach. This paper puts forward an "upstream" perspective on OHS in small workplaces that moves beyond the attributes of the workplace and those who work there. The paper draws on and synthesizes ideas and findings from emerging upstream OHS research, our own empirical investigations in Ontario and Quebec, and our collected research experience in small workplace health. Upstream structures and processes (regulations, policies, services, interventions, professional practices) are often misaligned with the conditions of work and social relations of small workplaces. Key upstream factors include regulatory exemption, subcontracting, unionization levels, the changing character of small enterprise, joint management, service and inspection constraints, competing institutional accountabilities, institutional orientation to large business, and inappropriate service and policy. Misalignment of the OHS system with the nature and practical realities of small workplaces can undermine prevention and the management of ill health and injury. To address such misalignments, the paper calls for: 1) restructuring of data collection and consultation processes to increase the visibility, voice and credibility of small workplaces; 2) "audits" of OHS-related legislation, policy and interventions to assess and address implications for small workplaces; 3) reflection on current terms and concepts that render workers invisible and capture poorly the essence and (increasing) diversity of these workplaces; and 4) extension of the upstream gaze to the global level.

This book explores how people encounter, understand, live with and respond to health risks associated with social, economic and political inequality. Complementing a traditional public health approach, the book moves beyond a focus on categories of morbidity and their structural causes. Instead, it focuses on everyday understandings and actions for people living in unequal social conditions. Making use of a variety of case studies related to physical and mental health, the authors emphasise interpersonal relationships, biographical meanings and the daily tactics of 'getting by'. These are recurrently linked to the social-structural aspects of particular times and places. The book: Draws upon, applies and extends the biopsychosocial approach, which is well known to students of public health. Respects and gives due weight to the experience in context of people who live with health inequalities, in domestic and local settings. Explores notions of personal agency and the contingencies of everyday life, in order to offer a focused psycho-social compliment to a public health tradition dominated by top-down reasoning. This is an important read for all those seeking to understand the complexities of health inequalities holistically in their studies, research and practice. The book brings together thinking in the fields of public health, sociology, mental health and social policy.

This report provides a comprehensive examination of political, policy, and economic factors that contributed to the failure of California's 2007 health care reform effort. Specifically, the report focuses on the intersection of four factors: 1) The impacts of long-term systemic forces or limitations — including economic forces, constitutional provisions, and federal statutes —over which state decision makers may have little control; 2) The critical policy challenges and the efforts to overcome them; 3) The perceptions, positions, and impact of major interest groups; and, 4) The role of political and legislative leadership in defining, promoting, and mobilizing support for reform goals. Relying on both extensive documentation and more than 120 interviews with reform participants and knowledgeable observers between January 2007 and July 2008, the author examines how these factors influenced and ultimately undermined an effort that had the support of both Democratic legislative leaders and a Republican governor. The report also examines the efficacy of sweeping reform efforts, highlighting the multiple challenges to comprehensive reform and the systemic rules which favor incremental over comprehensive reform. It concludes that, especially in difficult economic times, federal reform — or at least increased federal financial support — may be the key to insurance coverage expansions. Walter Zelman, PhD, was a visiting researcher at the UCLA Center for Health Policy Research and a visiting professor in the Department of Health Services at the UCLA School of Public Health during the data collection phase of this project. He is now Chair of the Department of Health Science and California State University, Los Angeles. Support for the data collection was provided by grants from The California Endowment and the University of California (UC) Office of the President, California Program on Access to Care.

Background: We rarely teach medical students the skills required to engage in policy change to address the structural factors that underpin the social determinants of health, which are driven by the unequal distribution of power and resources in society. Acquiring the knowledge and skills to influence policy can empower students to act on healthcare inequities rather than simply be aware of them. Methods: Using Metzl and Hansen's structural competency framework, we designed and piloted an intervention for medical students. Participants attended a workshop, presented to a hypothetical political stakeholder, and wrote an opinion editorial piece. Students participated in a focus group that was audio-recorded and transcribed. We coded and analyzed presentations, editorials, and transcripts to develop a thematic analysis. Results: Nine students participated in the workshop. They chose structural interventions and presented potential solutions to structural barriers in written and oral outputs. Students identified a lack of knowledge about health and political systems as a potential barrier to future advocacy work. Conclusion: Medical trainees require training in specific advocacy skills such as oral and written communication, however this alone may be insufficient. As future advocates, trainees must also acquire a specific skill set and associated knowledge about health systems and policy to navigate the systems in which they will practice.

"Social Determinants of Health introduces a range of topics related to health and well-being in the context of a conceptual framework of determinants of health. It provides an introduction to some of the important ideas that underlie the field of public health, aiming to give students an understanding of the causes of health, rather than just the effects of health status in society.By examining the social, cultural, economic and environmental determinants of health, students will gain a greater understanding of current issues in public health in terms of their causes and interrelationships. This book demonstrates how an understanding of social determinants will support students to become knowledgeable health professionals allowing them to practise effectively in the modern healthcare context." -- Provided by publisher