Social determinants of health

Stories of positive action from around the world

Story numbers correspond to those in the Report.

Building a flourishing living environment

6.3: South coast of England: a randomised trial of housing upgrading and health

Although outwardly affluent, the city of Torquay in the south of England has pockets of deprivation. Watcombe is an estate of former council-owned properties with much higher levels of deprivation than the regional average and the highest out-of-hours visiting rate by family doctors in the town – 15% above the town average. Half the estate population was receiving benefits and 45% of children under 5 years old were living in single-parent households.

A randomized-to-waiting list design was agreed with residents and the Council. The intervention comprised upgrading houses (including central heating, ventilation, rewiring, insulation, and re-roofing) in two phases, a year apart. Evaluation of the intervention was positive. The interventions succeeded in producing warmer, drier houses that were more energy efficient as measured by changes in the indoor environment and energy rating of the house. Residents appreciated the improvements and felt their health and well-being had improved as a result. Greater use of the whole house, improved relationships within families, and a greater sense of self-esteem were all mentioned as benefits. For those living in intervention houses, non-asthmarelated chest problems and the combined asthma symptom score for adults diminished significantly compared with those living in control houses.

Source: Barton et al., 2007

6.9: Community mobilization against violence in Brazil

Brazil has one of the highest homicide rates in the world. Between 1980 and 2002, the national homicide rate more than doubled, from 11.4 to 28.4 per 100 000 population. In São Paulo city, the homicide rate more than tripled during the same period, from 17.5 to 53.9 per 100 000 population. Jardim Angela is a conglomerate of slums located in the southern region of São Paulo city, with about 250 000 inhabitants. In July 1996, Brazil’s Veja magazine reported an average homicide rate of 111 per 100 000 population, ranking this region as one of the most violent in the world. Jardim Angela was experiencing what has been termed the urban penalty, which was characterized in this case by structural violence, mistrust, and lack of social cohesion. In 1996, a community integrated effort of 200 institutions called Fórum de Defesa da Vida (Life Defense Forum) was created. Parallel to the creation of this alliance, a social protection network involving civil society was organized, capitalizing on community capacity, social movements, and formal and informal health and social services.

This network engaged in a broad range of community interventions ranging from providing assistance to recently incarcerated children to a collective initiative for rebuilding community spaces. As a result of the investment in community space, abandoned spaces such as squares, clubs, and schools were rebuilt, providing space for sports, complementary school activities, and alcohol- and drug-abuse programmes. The community and police also established a coalition aimed at securing community welfare through surveillance of violence, criminality, and drug traffic. A range of policies and services were also implemented with community input including closing times for bars, a programme for victims of domestic violence, and health promotion interventions aimed at reducing teen pregnancy. In 2005, the homicide rate for the City and State of São Paulo was 24 per 100 000 population and 18 per 100 000 population, respectively, reflecting a 51% reduction in homicide for the State. More recently, from January to July 2006, Jardim Angela experienced a more than 50% reduction in reports of muggings, assaults, pick pocketing, and car thefts compared with previous years. Source: KNUS, 2007

6.12: Thai rural health services

Since 1983, the Thai government health budget allocation to rural district hospitals and health centres has been greater than that given to urban hospitals. As a result, there was extensive geographical coverage of health services to the most peripheral level. Today, a typical health centre and district hospital cover populations of 5000 and 50 000, respectively. Health centres are staffed by a team of 3-5 nurses and paramedics, while a 30-bed district hospital is staffed by 3-4 general physicians, 30 nurses, 2-3 pharmacists, a dentist, and other paramedics – acceptable numbers of qualified staff to provide health services. In addition, there were integrations of public health programmes (prevention, disease control, and health promotion) at all levels of care.

As all public health and medicine graduates are produced by publicly funded medical colleges, students are heavily subsidized by the government. In return, mandatory rural service by new graduates, notably at district hospitals, is enforced. This plays a significant role in the functioning of district hospitals. The programme started with medical graduates in 1972; it later extended to other groups including nurses, dentists, and pharmacists. Source: HSKN, 2007