Miriam van Den Berg

Tasmania has some of Australia’s worst potentially preventable hospitalisation (PPH) rates linked to chronic illness. This means that people are living with increasing pain and incapacity. PPHs are also an unnecessary social and financial cost and signal a failure to address the drivers of chronic illness, disproportionally experienced by people with poor access to the social determinants of health. Systems thinking (ST) is increasingly being applied to understanding such problems and designing solutions from a whole system perspective. This case study describes a novel, exploratory application of ST tools in four communities with high chronic disease risk to better understand and develop place-based interventions in the prevention approach known as ‘Anticipatory Care’ (AC). With community members, recruited through four community bodies, we used causal loop diagrams (CLDs) to implement three of the WHO’s recommended steps to ST in health systems: collectively brainstorm, conceptualise effects, and adapt and redesign. Community stakeholders developed CLDs to understand the locally relevant AC system, determine boundaries and priorities, and identify barriers to and opportunities for change. Opportunities focused on the relationship between safe access, place, belonging, relationships and culture, health information, and health services. At the project’s end, a second set of CLDs identified indicators of changes to local AC systems. Given a ‘blank slate’ for chronic disease prevention, communities developed unique, place-based responses orientated towards strengthening resources, connections, and collaboration. We argue that ST can be used to support community understanding of the behaviour of the local chronic disease prevention system, surface the interdependence of system parts, and identify formerly unrecognised opportunities for and consequences of intervention. The impact of place-based approaches is constrained by structural forces, including policies, norms, institutions, and resourcing.

Employment-related suicide is a global public health problem, which is becoming more urgent as the world’s workforce is increasingly employed under i

Public health scholars are increasingly interested in the Marxist concept of alienation to explain the existence of health inequities. Marx’s use of the term stresses the crucial role of political economic structural factors in creating alienation. This article reports on a narrative review of literature that used Marx’s theory of alienation and focuses on the mental and/or physical health effects of alienation. Our search resulted in 34 relevant articles. Collectively, they demonstrate the ongoing relevance of the concept of alienation to the creation of health inequities in contemporary society. Alienation results from the structure of class relations which are reflected in poor working conditions in which people do not receive the true worth of their labour and are alienated from themselves, others and nature. Alienation affects both workers and managers with effects resulting from their class positions. Consumption has also been identified as a cause of alienation particularly seen through the ceaseless advertising to persuade people to consume objects which do not yield satisfaction. Consumption creates alienation when bodies are commodified, and health services run for profit. We conclude that alienation is highly relevant to contemporary public health advocacy and practice by focusing attention on structural causes of health inequities.

Progress in addressing systematic health inequities, both between and within countries, has been slow. However, there are examples of actions taken on social determinants of health and policy changes aimed at shaping the underlying sociopolitical context that drives these inequities. Using case study methodology, this article identifies five countries (Ethiopia, Jordan, Spain, Sri Lanka and Vietnam) that made progress on health equity during 2011–2021 and three countries (Afghanistan, Nigeria and the USA) that had not made the same gains. The case studies revealed social, cultural and political conditions that appeared to be prerequisites for enhancing health equity. Data related to population health outcomes, human development, poverty, universal healthcare, gender equity, sociocultural narratives, political stability and leadership, governance, peace, democracy, willingness to collaborate, social protection and the Sustainable Development Goals were interrogated revealing four key factors that help advance health equity. These were (1) action directed at structural determinants of health inequities, for example, sociopolitical conditions that determine the distribution of resources and opportunities based on gender, race, ethnicity and geographical location; (2) leadership and good governance, for example, the degree of freedom, and the absence of violence and terrorism; (3) a health equity lens for policy development, for example, facilitating the uptake of a health equity agenda through cross-sector policies and (4) taking action to level the social gradient in health through a combination of universal and targeted approaches. Reducing health inequities is a complex and challenging task. The countries in this study do not reveal guaranteed recipes for progressing health equity; however, the efforts should be recognised, as well as lessons learnt from countries struggling to make progress.

Employment conditions are important social and commercial determinants of health. Informal employment—also known as ‘cash-in-hand’ and ‘undeclared’ work—is a discrete employment condition that has salience around the world. Fuelled by neoliberal ideology, informal employment has become increasingly common in high-income countries. Public health research concerning the health of informal workers comes largely from low- and middle-income countries, where the phenomenon is more visible. There has been little research on the health effects of informal employment in high-income countries including Australia. Twenty-nine workers aged 18 years and older, who were undertaking informal work activities, were recruited using social media and an online marketplace in Tarndanya (Adelaide-Kaurna Country), Australia. Qualitative narrative data, demographic profiles, and physical and mental health scores were collected. Most informal workers reported unfair and indecent employment conditions including job insecurity, low income, coercion, and lack of respect and dignity at work, and were often exposed to unsafe and unhealthy work environments. Workplace injuries and exposure to occupational hazards were common; and Physical and Mental Component Scores were poorer among informal workers when compared to the population of South Australia as a whole. With informal employment in Australia described as part of a ‘significant, pervasive, damaging and growing’ problem, there is a need for a health promotion lens over industrial relations policies in the interest of creating equitable access to fair and decent work.