Health in Society Lectures - Hoorcolleges Health in Society Hoorcollege 1: Introduction to new - Studeersnel (2023)

Hoorcolleges Health in Society

Hoorcollege 1: Introduction to new public health

Deel 1 over de opbouw van de cursus, staat in cursushandleiding

Health is a social issue

WHO: a majority people in the world do not enjoy good health because of acombination of bad policies, economics, and politics!!

Social determinants = anything outside the individual’s influenceSocial determinants of health = conditions in which people born, work, live, growand age

Inequalities in health do not rise from inequalities in health systems, but theconditions above. Poor people have more damaging behaviours (e. alcoholism)due to the way society is shaped...

The way we think about health, decides how we think about health promotion.We view that there are not only individual factors contributing to suboptimalhealth. Interventions should not only target individuals:

Health interventions: education, coping skills, teaching healthy lifestyle blablaSocial policy: ‘higher’ level, affects distal factors

A lot of stakeholders play a role: different ministries (health, traffic, infrastructure,belastingdienst), employers, climate organizations


What is health?

Clockwork model in medicineThe idea to view the body as a clock, a machine. The biomedical perspective.Focuses on breakdowns: disease. Classifying, understanding, identifying diseasesis Very Important in medicine.

Objective: keeping the machine runningHealth: when the body operates efficiently

But:  health is more than an absence of illness  no consideration of mental health  it presumes a normal state of health, this is different for everyone

WHO formulated it like this:“Health is a state of complete, physical, mental, and social well-being and notmerely theabsence of disease or infirmity.”

Positive health is more difficult to formulate, aspects important here are:  strengths that contribute to good health and protect against illness  physical, mental, spiritual aspects  daily functioning, social participation  quality of life

What is public health?  Health of populations rather than individuals (holistic/ecosystems)  Prevention approach rather than treatment (protecting groups)  Collective rather than personal interventions (focus on places, settings, locations)

Roots:Infectious diseases that were to be combattedCollective health measures have existed throughout history, but we speak of thestart as being in the beginning of 19th century

McKeown: Improved living standards aremore important than medical advances.See the graph: before a cure, less peopledied already of the diseaseSzreter: not living standards, but thepublic health movement that improvedworking conditions, education, healthservices, housing... Not just the fact thatpeople had improved living standards,more money for food for example, butalso the way these improved economicconditions were invested

Green: health can only be promoted and changed is supportivePurple: well reachable, diverseBlue: more traditional perspective, providing knowledge about healthOrange: people determine policy

Contributing to a better world 

There are 17 goals, not sure why this is important euh but here they are:

Importance of evidenceThis is relevant to the group assignment 

Often people jump to solutions without analyzing the problems to be addressed fully. A thorough analysis of the problem is needed first!!!! Yet another scheme/picture/whatever:

Two main issues for researchWhat are causes of (and contributors to) health?  Individual, social, structural factors  Biology, behaviour, support, environment, policy, economyEffectiveness of policies and interventions  Which approach effectively influences underlying factors?  Individual, social, and structural approaches to change

Such fun, we do this in the group assignment.

Hoorcollege 2: Politics, inequity, and social determinants of health

Politics, equity, and social determinants of health

Public health is a political processHealth is influenced by social factorsPolitical decisions and policy have a substantial influence of the health ofpeople/populations

This is seen during the covid-19 pandemic, big role of leadership and politics.The pandemic causes issues in different dimensions:  Population health  Health system capacity  Wellbeing/mental health  Economic & cultural life (e., access to festivals and museums)  National and international (vaccination rates in different countries...)

Is public health always political?

Link politics and public health  Public health is more than a technical issue for professionals and experts  Evidence requires understanding  Limited resources imply choicesAny decision is shaped by values and preferences, ideologies and worldviews.Politics shape how we understand health issues; what we think causes is, whatwe think is the right response.

Finding common ground?It is hard to find a middle ground between leaving everything to the individualand implementing a lot of rules.Examples that kind of do this:  Nudging, do not restrict freedom, do push certain healthy choices  Changing choice architecture!! Such as fancy stairs next to escalators, points to stand during covid-Bridging autonomy – paternalism

Other factors:Geopolitical developments  Shift towards neo-liberal political systems (market dominant force)  GlobalizationWhat are implications?  More transportation and infrastructure, also provides structure for rapid spread of communicable diseases (covid lol)  Health as a global market commodity, for example selling masks

Why is health affected by neo-liberal globalization?  Prioritizing economic growth (negative effect on sustainability)  Promoting consumer cultures  Privatization services (not all services are profitable and may disappear)  Focused on business interest (profit!!)  Growing social inequities (poorer getting les poor, rich richer faster)  Lack of global governance (no regulation of globalization like tech companies)

Political determinants of healthNorms, policies, and practices arising from global political interaction across allsectors that affect health

How can we influence politics?Advocacy and activism!!Civil society can effect change:  Collective efficacy, empowerment  Strengthening community actionMovements like climate change protests, world social forum, people’s healthmovement

Social position, inequity, and public health Social position may influence health. Poorer people cannot afford healthpromoting technologies, for example.

Life expectancy has increased across the globe! Did not start at the same timeand is not as high everywhere. Economic development associated with lifeexpectancy and population health.

Social inequality within countriesThe higher people are educated, the higher their health and wellbeing and lifeexpectancy. Differences do also play out in the Netherlands and Sweden!!

Socio-economic positionSocial class, indicators are income, education, occupationThis status can be measured at levels: individual, family, neighbourhood, country

Worse health on various indicators:  Income, wealth  Poverty, unemployment  Educational achievement  Occupation (physical and social demand)

These are theSocial determinants of healthConditions in which people are born, grow, live work and age.Shaped by inequities in power, money, and resources!People in deprived neighbourhoods are people with less resources, has anadverse impact on health

Our health is not an individual matter, but a matter of the circumstances. Weneed social policies to make it equal!!!

Theories of health inequitiesWhy poorer people less healthy than rich?

  • Methodological artefactIf you control for factors, the difference disappears. Differences do not exist(what)Not true lol
  • Natural/social selectionHealth and ability can affect social position. Able people are richer. OOF. Likelyonly true for a small portion of differences between groups
  • Behavioural/cultural factorsLess-well off adopt less healthy lifestylesWhere do these differences come from...?
  • Material/structural factorsEconomic well-off have more social and cultural resourcesMore likely, ability to buy healthier food and treatments
  • Psychosocial processesStress related to disadvantaged/ lower statusAlso likely?? Poorer people might smoke/drink more to cope with stress, andstress has a direct negative impact as well on health

Stigma as social determinant??Sexual minority individuals experience stigmatizationSeen as fundamental cause of health inequityStereotyping and discrimination is imbedded in institutionsStress negatively affect coping and mental health!

Hoorcollege 3: Health, environments & societies

Chapter 14-

How do environmental issues affect health? E., pollution and climate changePhysical environment has a massive influence on health of individuals andpopulation

Environmental health issues reflect the organization of societies

Health outcomes are affected by various influences, see picture.There are direct effects, as well as indirect effects.

INERTIA in responding to environmental health treatsWhy are we so slow in responding to these threats?Power and agency are key in this, as well as opposing goals

Opposing parties:  People who want to preserve their wealth  Interest of future generations and low-lying countries

Between and within countries there are power differentials.

Societal arrangementsWe need to change these arrangements  Changing behaviours and systems (like water bottles recycling, systems: plastic wrapping in supermarkets)  Dominant capitalist economic model: centered around ownership, profits, market, consumption  Social disparities in risk and resources: environmental risks are not evenly distributed: where people are rich and thus have resources, they are also at lower risk PFFF

The more economic disadvantaged people are, the more they are faced withenvironmental health treats. This is between countries, but also within countries(TATA!!).

We call this:Environmental injusticeSocial inequity in the geographic distribution of environmental risks andresources.

Promoting!! Environmental justice  Both a principle and a movement  Ensuring fair treatment and meaningful involvement (people want their concerns to be heard and addressed)  Distributive and procedural (involvement) justice  Democratic science/ citizen science

Climate justiceBegins with recognizing the differences in consequences for certain groupsClimate impacts can exacerbate inequitable social conditions

Part 3

Healthy economic policiesEnvironmental health threats need changes to our systems, like economicsystems. Makes it hard!!

‘Health improvements as part of an overall development pattern based oneconomic growth’The richer an economy gets, the better the health of a society getsEUHHh

Explosion of gross domestic product: we’ve become RICHH

Generally, this is true: world health is better than it was centuries ago; e.,higher life expectancyBut this is not equally distributed

Adverse effects of growth  Climate change, environmental degradation  Depletion of non-renewable sources  Impact on personal and social wellbeing (work-life balance, less time for parenting and caring, social engagement)

GDP is not the only indicator of how an economy is doing. Happy planet index isan example of showing how well people are doing in a country  says somethingabout economy as well!!!

Green economicsWe should transform economics to one that supports life on earth:  Energy sources and use  Active, public transport  Recycling, circularity  Restoration of nature  Local food production

An important concept! But also lot of kritiek

Questioning assumptions  Ecological sustainability requires limiting economic growth?  Is wellbeing positively associated with economic growth?

 Complete: mix of uses Compact: walkable scale Connected: transport, social Complex: variaton Convivial: lively, friendly, enjoyable

Healthy infrastructureIF makes living in cities possible, have influence on health in populations:

  • Sustainable energy use
  • Equitable infrastructures (housing NL...)
  • Increasing amount of green space
  • Attractive non-urban areas
  • Experienced neighborhood safety
  • Changing place of the car

Hoorcollege 4: Medical and behavioral perspectives on health


Three perspectives in this lecture, medical, behavioral and a bonus... preview.

Medical approach to health promotion  Focus on absence of disease and disability  Decrease in morbidity and mortality; decrease in physiological risk factors

How?Of course, with health services. Focus on prevention and treatment.

PreventionThrough comprehensive primary care, GPSome examples:

ScreeningsBevolkingsonderzoek, early detection and subsequent actionThis may be actually most effective in healthies/lowest risk groups (huh). Theyare most likely to use the opportunities:

  • Lack of access
  • Just not going

But wait... The people who need it, are not using it. Healthy people will gethealthier, risky people riskier. = GROWING INEQUITY

Rose: “You can not reduce the proportion of the population at high risk withoutreducing the whole society’s exposure to the risk.”

ImmunizationAnother example of prevention.

  • Success depends on herd immunity: sufficiently high level of immunization (95%)
  • Undervaccination: causes are lack of acceptance and/or lack of access

In NL: Bible belt has lower vaccination... Medical professionals can’t really fix this.So:We need to address social and structural levels to improve immunization success

Limitations of the medical approachThe medical approach corresponds with the clockwork model:  Health seen as absence of disease  Curative focus, physiological risk factors

Focusing only on curing, rather than on focusing on people as a whole (mentalhealth, wellbeing, communities), very limited perception of health promotion

Can this induce sustained behavior change? (NO)

Narrow focus, narrow reach  Does not address socio-environmental factors  Does not address the whole conceptualization of health  Does not reach the people who need help most

Focus on inequity (NPH)Makes everything worse lol...Individuals with low SES are less likely to

  • have access to adequate health care
  • actively seek out adequate health care
  • understand medical advice and treatment recommendations
  • receive adequate health care

Video on racial disparities: implicit association test suggests that doctors preferwhite patients. Might affect diagnosis and care. Lot of very sad data found onracism. Cultural/language differences, stereotypes; all causes. A fix could berepresentation? Or cross-cultural education? Not really working.

Behavioral approach to health promotion  Individual practice of healthy behaviors  Decrease in unhealthy (risky) behaviors

A LOT of behavior change techniques, example:

  • Increasing knowledge, so people are more motivated to be healthy (or less risky)

3 Limited effects: excessive focus on individual

  • We continuously interact with environments
  • We cannot (always) control or change our environments

Understanding effects is difficult  Which components are effective?  For whom is it effective?Hard to find out

Focus on inequity in NPHMakes it WORSE

Individuals with low SES are less likely to

  • perceive the need for health behavior change
  • participate in health behavior change interventions
  • stick with a health behavior change intervention program, if they start one
  • benefit from health behavior change intervention programs

We need to better understand the reasons behind these main problems

Evolving behavior change theory: COM-B modelWants to fix limitations of this approach:

Socio-environmental approach  Environment: healthy settings  Increase in wellbeing  Decrease in health inequity

Next week more detailed maar dat is John de Witt hahahaha

Focus not on treating a person or motivating a person, but on the whole!

Key points

  • The ways in which society is shaped (socially/structurally) exerts powerful influence over behaviour, choices, opportunities, and capabilities

  • Social: networks; social groups; social capital; social support; social cohesion

  • Structural: structure of society (e. social class, but also privatization); designof environments; global, national, local policies

These factors should be addressed! More next week xx

Hoorcollege 5: enabling individuals and empowering communities

We focus on nr. 3.Broader context of wellbeing and social inequity

Socio-environmental approachRose: “You can not reduce the proportion of the population at high risk withoutreducing the whole society’s exposure to the risk.”

A holistic approach

Filmpje na deel 2 over healthy settings:Lagging behind of health in prisons, political cause. Not everybody wants to useresources for that.Arguments against settings approach:1 Bigger inequity, disadvantaged groups don’t have a lot of settings(unemployed, homeless)2 Gap between theory and practice3 No real proof it is effective? Very hard since the holistic character

Nudging  Alternative strategy!!  Balance between individual (behavior) and collective (socio-environmental) approaches  Libertarian paternalism? Freedom to choose behavior, paternalism in the way it steers in a particular direction

Example: organ donationDemand higher than supply? Whyyyy?

  • Status quo bias/inertia: tendency to prefer a situation as it is, even if this is not the best for ourself or society (lazy??).Could be fixed by opt-out option. Automatically being registered as donor (whydoes this seem unethical?).

What’s in a nudge?  Deliberate intention to influence  Use of non-conscious processes  Compensation for cognitive limitations (like inertia)  Valorizing the preferred option  Goal-directedness – intent to do good  Respecting freedom of choice

People generally are supportive of nudges, as long as choices can still be freelymade.

Are nudges ethical?They are non-coercive and preserve choice...BUT!!!

  • Are people aware and can they avoid nudges?
  • How easy/cheap will it be to choose differently?
  • Who decides what is beneficial for people?
  • Does/will the end justify the means?
  • Will nudging replace other approaches (e., education, social debates)?There is an importance of transparency and debate!

Strengthening community action (er was geen oranje  )Participation, advocacy, activism

Participation in health promotion  Communities can and should determine their own priorities  Collective experience/knowledge for change/improvements (many contributions help effectiveness)  When people understand a problem, they more readily act

 People best solve their problems in a participatory process


  • Patient participation group
  • Community advisory boards
  • Community organization
  • Co-design and co-creation of interventions

Issues around participationNot all participation is real.Power differences

Beetje vaag...

Tokenism = symboliek

Blue is ideal.Mostly participation is green,sometimes partnership

Community development in healthEmpowerment! Strengthening communities to look after themselves.

Communities and processesCharacteristics of community:

  • spatial (incl. online) or non-spatial (identity)
  • social relations: shared needs and concernsRole of social capital is important (Bourdieu)
  • networks, trust, cooperation -> better outcomes
  • distribution of opportunities and resources (some members may have more, some less)

Community strengthening

Two dimensions in terms of approach:Consensus between community andother -stakeholder, or conflictNeeds-based (to fix problemssomething is needed) or strengths-based (try to build on what’s alreadyavailable)


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