Social determinants of health (SDH) are specific conditions of people’s lives, which determine their health and well-being in general (Frank et al., 2020; Lucyk & McLaren, 2017). Examples are education level, socioeconomic status, common problems such as obesity, mental health issues, and environmental settings. Urban health and health equity are other factors, important for modern world. The problem of inequity is widespread; to solve it, progressive health policies are necessary, especially at the local levels. As city population rise everywhere in the world, urban health measures are essential to provide well-being: examples of them are city parks establishment, pollution reducing and providing accessible medicine and education (Astell-Burt & Feng, 2019; Lowe et al., 2020; Paul Rosenberg (Health officer) et al., 2016). City councils create organizations, such as the Alliance for healthy cities, to ensure the usage of progressive health policies (Acuto et al., 2016; Leeuw & Simos, 2018; Lowe et al., 2020).
Literature Search Strategy
Most of the literature was found in PubMed: a good and extensive database of articles related to health, medicine, and biology. Other parts of the literature are reviews, releases, and articles from the World Health Organization website. The one source is used from the Gold Coast City website as an example of an urban health measure (Gold Coast City Council, 2021). The search was conducted based on keywords, such as “urban health,” “health equity,” and “social determinants of health.”
Criteria for the literature search were as follow:
- Articles should describe either social determinants of health in general or be focused on one of them, such as health equity, urban health, or environmental settings.
- Articles can be either a global review and study of social determinants of health and their policies or be focused on implementing health policies in some particular territory.
- WHO resources show current health inequity and urban health issues and the policies intended to solve those issues.
- Health equity and urban health are the main topics of the current review; thus, articles focused on them are the priority.
- Articles that describe the Australian health policies and SDH are the priority. Those describing other countries, such as Norway and the United States, are also eligible to show the trends
What is Meant by Urban Health, Health Equity, and Social Determinant of Health
Definitions
Social determinants of health (SDH) are the factors that show the current state of health and well-being of the population. They are developing as more factors are researched and determined; some examples are health literacy level, environmental settings, access to the healthcare for the population (Frank et al., 2020; Lawless et al., 2016; Lucyk & McLaren, 2017). They can be presented both as the models and the influential factors, and those concepts, overlapping, can create confusion (Lucyk & McLaren, 2017). Still, it is a valuable instrument to evaluate the population’s health and develop approaches to improve it.
Health equity is the absence of unfair and avoidable differences among people that prevents them from the access to the health services, to fully realize their well-being potential (Health Equity — Global, 2021). Those differences are present worldwide, which creates a huge concern (Urban Health: Major Opportunities for Improving Global Health Outcomes, despite Persistent Health Inequities, 2016; WHO, 2021). For example, in the United States, where 12.1% of the population has diabetes, mortality rates are higher among the people with a low income and significantly higher among the Native American population (Haire-Joshu & Hill-Briggs, 2019; Shah et al., 2015). Similarly, in Australia, Aboriginal populations are more vulnerable to health issues (Backholer et al., 2021; Pearson et al., 2020). In that way, ensuring equity is crucial for public health.
Urban health includes a set of measures used to provide a healthy life in the cities. In Australia, there is evidence that people exposed to the green canopy are less likely to feel distressed, anxiety and other mental issues (Astell-Burt & Feng, 2019). Governments also create policies to promote physical activities, a lack of which is typical for city populations and worsens their health. (Candio et al., 2021; Durham et al., 2019; Leeuw & Simos, 2018; Paul Rosenberg (Health officer) et al., 2016). According to the article, it also improves health equity, as all population obtains access to sports grounds.
Environmental and social issues are closely connected with urban health issues. For example, there is evidence that Australian supermarkets promote unhealthy food (Grigsby-Duffy et al., 2020). Alcohol consumption is widespread and dangerous: 13.5 % of all deaths in 20-39 are connected with alcohol consumption (WHO, 2018). In that way, governments can increase public health by establishing and promoting healthy diets, similar to promoting physical activity (Barbour et al., 2021). Air pollution is another issue: worldwide, approximately 7 million deaths in the year are connected to pollution (Health Benefits Far Outweigh the Costs of Meeting Climate Change Goals, 2018). Health equities is a challenge for cities: according to the analysis of city households in 97 countries, the wealthiest 20% have access to clean water 2.7 times more likely than the poorest 20% (Urban Health: Major Opportunities for Improving Global Health Outcomes, despite Persistent Health Inequities, 2016).
Measurements and Policies
To measure health equity, researchers should first define the inequity and search for its examples. Health Inequalities Assessment Toolkit (HIAT) uses interviews, focus groups, and workshops to gather information and evaluate the level of inequity in different societies (Porroche-Escudero & Popay, 2019). To create a model, researchers can use the health equity measurement framework: it includes the social, economic, and cultural context of the population, social stratification, environmental settings, and general healthcare quality (Dover & Belon, 2019). The Urban Health Index can be used for urban health, as recommended by the WHO: it uses the parameters of health indicators, health determinants, area boundaries, and demographic base (Leeuw & Simos, 2018; Weaver et al., 2014). Those measures are used to evaluate the situation with healthcare in the population and see how to improve it.
Policies directed on improving health equity are different and treat the problem from different sides. One of them is providing and maintaining social equity: gender, racial, national (Centers of Disease Control, 2017; WHO, 2021; Woodruff, 2021). It ensures that all classes of the population will have access to education and health services and will be able to maintain their health. In Australia, research policy advisory groups (PAGs) conduct research and stimulate the population’s knowledge flow, improving its health literacy (van Eyk et al., 2020). Health literacy is essential, as the population with high literacy care more about themselves and are more critical to health issues (Nutbeam & Lloyd, 2021). To solve health inequalities, researchers produced a plan to eliminate them by the 2030 year (Backholer et al., 2021). The methods are implementing the policies that promote collaboration, address social inequalities between white and Aboriginal populations, and use technologies to solve environmental problems and digitalize the public health field.
The Alliance for Healthy Cities
The Alliance for healthy cities was formed to address urban health issues and develop and implement policies that can efficiently solve them. Gold Coast City is a member of the Alliance: its website shows healthcare and environmental policies, such as regular water monitoring (Alliance for healthy cities; Gold Coast City Council, 2021). City networking is the process of communication between city governments, both on national and international levels, and the Alliance is an example of such city networks (Acuto & Morissette, 2016). Its full members can be city governments and governing units such as municipality organizations. Individuals and other organizations can be admitted as associate members.
The Healthy Cities programme is developed with the WHO and aims to increase the networking between cities, improving its quality (A. Lee & Nakamura, 2021; Leeuw & Simos, 2018). According to the research, there is a problem with the low quality of the networking: city governments talk about the opportunities but not about specific strategies (Acuto & Morissette, 2016). This programme tends to solve that problem and ensure high-level communication about urban health issues. The Alliance for healthy cities developed the SPIRIT framework, ensuring the holistic approach to urban health (A. Lee & Nakamura, 2021). SPIRIT stands for Setting and Sustainability, Political commitment and Policy, Information and Innovation, Research and Resources, Infrastructure and Intersectoral, and Training. The framework aims to evaluate and address all social determinants of health connected with city populations: environmental, social, cultural issues, inequalities, behaviour typical for the particular city (A. Lee & Nakamura, 2021; Redman et al., 2015). Then, the Alliance engages key stakeholders from the healthcare industry to launch various health-improving programs to solve identified issues (Acuto & Morissette, 2016; Alliance for healthy cities; Leeuw & Simos, 2018). In that way, the Alliance helps to improve the urban health of its city members.
Diplomacy between cities is an important element of urban health: they can share their best policies and the experience of their implementation, which will improve the public health in all cities engaged (Acuto et al., 2016; WHO Team: Air quality and health, 2021). According to research, Australia lacks policies to establish a healthy city environment, despite the general aspiration to liveability (Lowe et al., 2020). The country solves those issues at the local level: for example, in the state of Victoria, the implementation of initiatives such as public gardens, community kitchens, and bicycle recycling helped reduce health inequity (Kay & Livingstone, 2020). Those initiatives positively impact the public health level in the state and promote health equity.
Barriers and Obstacles to Health Equity
COVID-19 pandemic exposed a lot of the existing problems in the public health area. According to the research conducted in Hong Kong, more than 60% of people experience high stress during the quarantine lockdown (A. Lee & Nakamura, 2021). The pandemic clearly showed that poor people are more vulnerable to illness and other diseases (Deslatte et al., 2020). The WHO has created and promoted a strategy to implement health equity worldwide (WHO, 2021). Solving the inequity problems is one of the most critical challenges for the modern world, but there are many barriers to doing this.
The main obstacle to health equity is that poor populations with insufficient resources usually cannot create better conditions for themselves. They are usually heavily exposed to the air and other pollutions and often work in an unhealthy environment (WHO Team: Air quality and health, 2021). This further worsens their state and leads to diseases, which crop the opportunities for them. Non-communicable diseases, which are especially typical for the cities, are results of the wrong environmental influences, such as pollution and stress; approximately 68% of deaths worldwide are connected with them (Paul Rosenberg (Health officer) et al., 2016). Examples of such diseases are cancer, diabetes, and mental illnesses. Personalization of the medicine, while promoting a better service and the usage of technologies, deepens the health inequalities if no policies are implemented to prevent it (Malbon et al., 2019). In that way, a lack of social mobility worsens the health of the population.
Lack of communication and health literacy is another barrier to health equality: those who do not know how to access healthcare and care for themselves are more likely to face health issues. In Australia, there is a lack of communication between local governments and public health organizations, negatively impacting the decision-making connected with health issues (Javanparast et al., 2018). There is an initiative to provide multisectoral policy implementation, reduce that lack of communication, and provide better decision-making (Baum et al., 2017). In general, improving health literacy among the population improves their health (Nutbeam & Lloyd, 2021). Another example is the position of the public health coordinator in Norway: it is a person who manages the distribution of public health facilities in a city or other community (Hagen et al., 2019). Such a policy positively influences the decision-making at the local government level. In that way, to ensure health equality, local governments should implement policies that improve public health literacy and initiate communications between different organizations and communities.
Conclusion and Gaps in the Research
There are many social determinants of health, and not all of them are presented equally in the researches. There are many studies and WHO reports connected with health equity problems, but they are mostly connected with Western countries, such as Europe, the U.S., and Australia, or with general health inequity issues in the world (Baum et al., 2018; Farrer et al., 2015; Haire-Joshu & Hill-Briggs, 2019; Hall et al., 2016; Harris et al., 2020; Malbon et al., 2019; Woodruff, 2021). Researches which studies health equity in the context of the COVID-19 pandemic are popular in modern days, despite only one of them being mentioned in this research (Deslatte et al., 2020). Urban health themes are popular and well-presented in the literature, from the WHO books and reports to research articles in different countries (Astell-Burt & Feng, 2019; Leeuw & Simos, 2018; Paul Rosenberg (Health officer) et al., 2016; WHO Team: Air quality and health, 2021). Environmental issues and social issues, which are also deeply connected with health issues, are well-presented and studied, as they are critical and well-recognized modern problems (Barbour et al., 2021; Baum et al., 2018; Grigsby-Duffy et al., 2020; Kay & Livingstone, 2020; Nutbeam & Lloyd, 2021; Health Benefits Far Outweigh the Costs of Meeting Climate Change Goals, 2018).
The literature which considers the Alliance for healthy cities is scarce: there are only indirect mentions of the Alliance in most of the literature. It is mostly mentioned as an example of a successful city network organization (Acuto et al., 2016). The SPIRIT framework, designed by the Alliance and used for improving urban health, is described in several articles, but similar approaches are underrepresented in the literature (A. Lee & Nakamura, 2021; Redman et al., 2015). There are much more literature examples considering the Healthy Cities approach in general, and present the Alliance as the part of successful implementation of this approach (Acuto et al., 2016; Leeuw & Simos, 2018; Paul Rosenberg (Health officer) et al., 2016).
The health studies in Australia can be considered as well-developed: there are many articles where the situation with urban health and health equity in Australian cities and states is studied (Astell-Burt & Feng, 2019; Baum et al., 2018; Delany-Crowe et al., 2019; Grigsby-Duffy et al., 2020). The Gold Coast City is not well-represented in studies, despite there being studies of the healthcare situation in the state of Queensland in general (Durham et al., 2019). For other countries, there are many articles exploring the Norwegian and Swedish situation with health equity and the initiatives and policies connected with it (Hagen et al., 2019; Hagen et al., 2016; van Vliet, 2018). There is much literature studying the health equality issues in the United States (Deslatte et al., 2020; Shah et al., 2015; Haire-Joshu & Hill-Briggs, 2019).
Health equity and urban health have big importance due to the rapid growth of city populations and the necessity to provide their healthcare. There is a need for policies to ensure high security, a clean environment, and a good healthcare level with equal access in cities. Successful experiences, such as public initiatives in Victoria state or health coordinators in Norway, should be used. City networks, such as the Alliance for Healthy Cities, help share the best policies and improve health in their populations. Communication between researchers measuring health inequity, local governments, and communities is crucial for improving health literacy and equity.
References
Acuto, M., Morissette, M., & Tsouros, A. (2016). City diplomacy: Towards more strategic networking? Learning with WHO Healthy Cities. Global Policy, 8(1), 14–22.
Alliance for healthy cities. Alliance for healthy cities.
Astell-Burt, T., & Feng, X. (2019). Association of urban green space with mental health and general health among adults in Australia. JAMA Network Open, 2(7), e198209.
Backholer, K., Baum, F., Finlay, S. M., Friel, S., Giles-Corti, B., Jones, A., Patrick, R., Shill, J., Townsend, B., Armstrong, F., Baker, P., Bowen, K., Browne, J., Büsst, C., Butt, A., Canuto, K., Canuto, K., Capon, A., Corben, K.,… Demaio, S. (2021). Australia in 2030: what is our path to health for all? Medical Journal of Australia, 214(S8).
Barbour, L., Lindberg, R., Woods, J., Charlton, K., & Brimblecombe, J. (2021). Local urban government policies to facilitate healthy and environmentally sustainable diet-related practices: A scoping review. Public Health Nutrition, 1–36.
Baum, F., Delany-Crowe, T., Fisher, M., MacDougall, C., Harris, P., McDermott, D., & Marinova, D. (2018). Qualitative protocol for understanding the contribution of Australian policy in the urban planning, justice, energy and environment sectors to promoting health and health equity. BMJ Open, 8(9), e025358.
Baum, F., & Friel, S. (2017). Politics, policies and processes: A multidisciplinary and multimethods research programme on policies on the social determinants of health inequity in Australia. BMJ Open, 7(12), e017772.
Candio, P., Meads, D., Hill, A. J., & Bojke, L. (2021). Taking a local government perspective for economic evaluation of a population-level programme to promote exercise. Health Policy, 125(5), 651–657.
Centers of Disease Control. (2017). Key policies for addressing the social determinants of health and health inequities (1st ed.). World Health Organization.
Delany-Crowe, T., Marinova, D., Fisher, M., McGreevy, M., & Baum, F. (2019). Australian policies on water management and climate change: are they supporting the sustainable development goals and improved health and well-being? Globalization and Health, 15(1).
Deslatte, A., Hatch, M. E., & Stokan, E. (2020). How can local governments address pandemic inequities? Public Administration Review, 80(5), 827–831.
Dover, D. C., & Belon, A. P. (2019). The health equity measurement framework: A comprehensive model to measure social inequities in health. International Journal for Equity in Health, 18(1).
Durham, J., Fa’avale, N., Fa’avale, A., Ziesman, C., Malama, E., Tafa, S., Taito, T., Etuale, J., Yaranamua, M., Utai, U., & Schubert, L. (2019). The impact and importance of place on health for young people of Pasifika descent in Queensland, Australia: A qualitative study towards developing meaningful health equity indicators. International Journal for Equity in Health, 18(1).
FARRER, L., MARINETTI, C., CAVACO, Y. K., & COSTONGS, C. (2015). Advocacy for health equity: A synthesis review. The Milbank Quarterly, 93(2), 392–437.
Frank, J., Abel, T., Campostrini, S., Cook, S., Lin, V. K., & McQueen, D. V. (2020). The social determinants of health: Time to Re-Think? International Journal of Environmental Research and Public Health, 17(16), 5856.
Gold Coast City Council. (2021). Water quality monitoring programs. City of Gold Coast.
Grigsby-Duffy, L., Schultz, S., Orellana, L., Robinson, E., Cameron, A. J., Marshall, J., Backholer, K., & Sacks, G. (2020). The healthiness of food and beverages on price promotion at promotional displays: A Cross-Sectional audit of Australian supermarkets. International Journal of Environmental Research and Public Health, 17(23), 9026.
Hagen, S., ØVergård, K. I., Helgesen, M. K., Fosse, E., & Torp, S. (2019). Health promotion at local level in Norway – who, what, when, and how: A response to recent commentaries. International Journal of Health Policy and Management, 8(4), 253–255.
Hagen, S., Torp, S., Helgesen, M., & Fosse, E. (2016). Promoting health by addressing living conditions in Norwegian municipalities. Health Promotion International, daw052.
Haire-Joshu, D., & Hill-Briggs, F. (2019). The next generation of diabetes translation: A path to health equity. Annual Review of Public Health, 40(1), 391–410.
Hall, M., Graffunder, C., & Metzler, M. (2016). Policy approaches to advancing health equity. Journal of Public Health Management and Practice, 22(Supplement 1), S50–S59.
Harris, P., Baum, F., Friel, S., Mackean, T., Schram, A., & Townsend, B. (2020). A glossary of theories for understanding power and policy for health equity. Journal of Epidemiology and Community Health, jech-2019.
Health benefits far outweigh the costs of meeting climate change goals. (2018). World Health Organization.
Health equity — global. (2021). World Health Organization.
Javanparast, S., Baum, F., Freeman, T., Ziersch, A., Henderson, J., & Mackean, T. (2018). Collaborative population health planning between Australian primary health care organisations and local government: Lost opportunity. Australian and New Zealand Journal of Public Health, 43(1), 68–74.
Kay, V. A., & Livingstone, C. H. (2020). Promoting environmental sustainability, equity and health in Victorian Primary Care Partnerships. Health Promotion Journal of Australia, 31(2), 298–308.
Lawless, A., Lane, A., Lewis, F., Baum, F., & Harris, P. (2016). Social determinants of health and local government: Understanding and uptake of ideas in two Australian states. Australian and New Zealand Journal of Public Health, 41(2), 204–209.
Lee, A., & Nakamura, K. (2021). Engaging diverse community groups to promote population health through Healthy City approach: Analysis of successful cases in Western Pacific Region. International Journal of Environmental Research and Public Health, 18(12), 6617.
Lee, J., Schram, A., Riley, E., Harris, P., Baum, F., Fisher, M., Freeman, T., & Friel, S. (2018). Addressing health equity through action on the social determinants of health: A global review of policy outcome evaluation methods. International Journal of Health Policy and Management, 7(7), 581–592.
Leeuw, D. E., & Simos, J. (2018). Healthy Cities: The theory, policy, and practice of Value-Based urban planning (Softcover reprint of the original 1st ed. 2017 ed.). Springer.
Lowe, M., Arundel, J., Hooper, P., Rozek, J., Higgs, C., Roberts, R., & Giles-Corti, B. (2020). Liveability aspirations and realities: Implementation of urban policies designed to create healthy cities in Australia. Social Science & Medicine, 245, 112713.
Lucyk, K., & McLaren, L. (2017). Taking stock of the social determinants of health: A scoping review. PLOS ONE, 12(5), e0177306.
Malbon, E., Carey, G., & Meltzer, A. (2019). Personalisation schemes in social care: Are they growing social and health inequalities? BMC Public Health, 19(1).
Nutbeam, D., & Lloyd, J. E. (2021). Understanding and responding to health literacy as a social determinant of health. Annual Review of Public Health, 42(1), 159–173.
Paul Rosenberg (Health officer), United Nations Human Settlements Programme, World Health Organization. Centre for Health Development, Rosenberg, P., United Nations Human Settlements Programme, World Health Organization. Centre for Health Development, & World Health Organization. Kobe Centre. (2016). Global Report on Urban Health. World Health Organization.
Pearson, O., Schwartzkopff, K., Dawson, A., Hagger, C., Karagi, A., Davy, C., Brown, A., & Braunack-Mayer, A. (2020). Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia. BMC Public Health, 20(1).
Porroche-Escudero, A., & Popay, J. (2019). The Health Inequalities Assessment Toolkit: Supporting integration of equity into applied health research. SSRN Electronic Journal.
Redman, S., Turner, T., Davies, H., Williamson, A., Haynes, A., Brennan, S., Milat, A., O’Connor, D., Blyth, F., Jorm, L., & Green, S. (2015). The SPIRIT Action Framework: A structured approach to selecting and testing strategies to increase the use of research in policy. Social Science & Medicine, 136–137, 147–155.
Shah, G. H., Luo, H., Winterbauer, N., & Madamala, K. (2015). Addressing psychological, mental health and other behavioural healthcare needs of the underserved populations in the United States: The role of local health departments. Perspectives in Public Health, 136(2), 86–92.
Townsend, B., Friel, S., Freeman, T., Schram, A., Strazdins, L., Labonte, R., Mackean, T., & Baum, F. (2020). Advancing a health equity agenda across multiple policy domains: A qualitative policy analysis of social, trade and welfare policy. BMJ Open, 10(11), e040180.
Urban health: Major opportunities for improving global health outcomes, despite persistent health inequities. (2016). World Health Organization.
van Eyk, H., Friel, S., Sainsbury, P., Boyd-Caine, T., Harris, P., MacDougall, C., Delany-Crowe, T., Musolino, C., & Baum, F. (2020). How do advisory groups contribute to healthy public policy research? International Journal of Public Health, 65(9), 1581–1591.
van Vliet, J. (2018). How to apply the evidence-based recommendations for greater health equity into policymaking and action at the local level? Scandinavian Journal of Public Health, 46(22_suppl), 28–36.
Weaver, S. R., Dai, D., Stauber, C., & Luo, R. (2014). The urban health index: A handbook for its calculation and use. World Health Organization.
WHO. (2018). Alcohol. World Health Organization.
WHO. (2021). Social determinants of health to advance equity. World Health Organization.
WHO Team: Air quality and health. (2021). Urban Health Initiative: A model process for catalysing change. World Health Organization.
Woodruff, T. (2021). Universal health coverage, non-communicable disease, and equity: Challenges to implementation comment on “universal health coverage for non-communicable diseases and health equity: Lessons from Australian primary healthcare.” International Journal of Health Policy and Management.
Appendix
The table of used literature