Public Health's Next Step in Advancing Equity: Re-evaluating Epistemological Assumptions to Move Social Determinants From Theory to Practice

Tasha L Golden, Monica L Wendel, Tasha L Golden, Monica L Wendel

Abstract

The field of public health has increasingly promoted a social ecological approach to health, shifting from an individual, biomedical paradigm to a recognition of social and structural determinants of health and health equity. Yet despite this shift, public health research and practice continue to privilege individual- and interpersonal-level measurements and interventions. Rather than adapting public health practice to social ecological theory, the field has layered new concepts ("root causes," "social determinants") onto a biomedical paradigm-attempting to answer questions presented by the social ecological schema with practices developed in response to biomedicine. This stymies health equity work before it begins-limiting the field's ability to broaden conceptions of well-being, redress histories of inequitable knowledge valuation, and advance systems-level change. To respond effectively to our knowledge of social determinants, public health must resolve the ongoing disconnect between social ecological theory and biomedically-driven practice. To that end, this article issues a clarion call to complete the shift from a biomedical to a social ecological paradigm, and provides a basis for moving theory into practice. It examines biomedicine's foundations and limitations, glosses existing critiques of the paradigm, and describes health equity challenges presented by over-reliance on conventional practices. It then offers theoretical and epistemological direction for developing innovative social ecological strategies that advance health equity.

Keywords: biomedical; epistemology; health disparities; health equity; innovation; research methods; social determinants; social ecological.

Copyright © 2020 Golden and Wendel.

Figures

Figure 1
Figure 1
Social ecological model of health. Adapted from McLeroy et al. (6) by Tasha Golden (7).
Figure 2
Figure 2
Effects of embedded biomedical practices on health equity.

References

    1. Knight EK. Shifting public health practice to advance health equity. J Publ Health Manage Pract. (2014) 20:188–96. 10.1097/PHH.0b013e31829959fb
    1. Plough A. Promoting social justice through public health policies, programs, and services. In: Hofrichter R, Bhatia R, editors. Tackling Health Inequities Through Public Health Practice: Theory to Action. New York, NY: Oxford University Press; (2010). p. 578.
    1. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Publ Health. (2011) 32:381–98. 10.1146/annurev-publhealth-031210-101218
    1. Al-Azri NH. Do we need a new medical paradigm? Oman Med J. (2012) 27:256–7. 10.5001/omj.2012.60
    1. Golden T. Innovation and Equity in Public Health Research: Testing Arts-Based Methods for Trauma-Informed, Culturally-Responsive Inquiry. Louisville, KY: University of Louisville; (2019).
    1. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. (1988) 15:351–77. 10.1177/109019818801500401
    1. Golden T. The Arts and Health Equity: Four Opportunities for Impact. (2019). Available online at:
    1. Wemrell M, Merlo J, Mulinari S, Hornborg A-C. Contemporary epidemiology: a review of critical discussions within the discipline and a call for further dialogue with social theory. Sociol Compass. (2016) 10:153–71. 10.1111/soc4.12345
    1. Adibi H. mHealth: its implications within the biomedical and social models of health - a critical review. Multidiscipl J Sci Technol J Select Areas Health Informatics. (2014) 4:16–23. Available online at:
    1. Brown L, Strega S. (editors). Trangressive possibilities. Research as Resistance. Toronto, ON: Canadian Scholars' Press; (2005). p. 1–18.
    1. Shy CM. The failure of academic epidemiology: witness for the prosecution. Am J Epidemiol. (1997) 145:479–84. 10.1093/oxfordjournals.aje.a009133
    1. Okagaki LH, Dean RA. The influence of funding sources on the scientific method. Mol Plant Pathol. (2016) 17:651–3. 10.1111/mpp.12380
    1. Jacobson N, Butterill D, Goering P. Organizational factors that influence university-based researchers' engagement in knowledge transfer activities. Sci. Commun. (2004). 25:246–59. 10.1177/1075547003262038
    1. Janßen C, Sauter S, Kowalski C. The influence of social determinants on the use of prevention and health promotion services: results of a systematic literature review. Psycho Soc Med. (2012) 9:Doc07. 10.3205/psm000085
    1. Coemans S, Hannes K. Researchers under the spell of the arts: two decades of using arts-based methods in community-based inquiry with vulnerable populations. Educ Res Rev. (2017) 22:34–49. 10.1016/j.edurev.2017.08.003
    1. Houghton T. Does Positivism Really Work in the Social Sciences? (2011). p. 1–5. Available online at:
    1. Carson D, Gilmore A, Perry C, Gronhaug K. Qualitative Marketing Research. London: Sage; (2001).
    1. House ER. Evaluating With Validity. Beverly Hills, CA: Sage Publications; (1980).
    1. Rigg KK, Cook HH, Murphy JW. Expanding the scope and relevance of health interventions: moving beyond clinical trials and behavior change models. Int J Qualitative Stud Health Well Being. (2014) 9:1–8. 10.3402/qhw.v9.24743
    1. Longino CF, Murphy JW. The Old Age Challenge to the Biomedical Model : Paradigm Strain and Health Policy. Baywood Publishing (1995). Available online at:
    1. Krieger N. Epidemiology and the People's Health: Theory and Context. Oxford: Oxford University Press; (2011).
    1. Centers for Disease Control and Prevention (CDC) Health in All Policies. (2019). Available online at:
    1. Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Publ Health. (2012) 102:936–45. 10.2105/AJPH.2011.300544
    1. Napier AD, Ancarno C, Butler B, Calabrese J, Chater A, Chatterjee H, et al. . Culture and health. Lancet. (2014) 384:1607–39. 10.1016/S0140-6736(14)61603-2
    1. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. (2010) 341:c4413. 10.1136/bmj.c4413
    1. Trickett EJ, Beehler S, Deutsch C, Green LW, Hawe P, McLeroy K, et al. . Advancing the science of community-level interventions. Am J Public Health. (2011) 101:1410–9. 10.2105/AJPH.2010.300113
    1. Osrin D, Azad K, Fernandez A, Manandhar DS, Mwansambo CW, Tripathy P, et al. . Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia. Bull World Health Organ. (2009) 87:772–9. 10.2471/BLT.08.051060
    1. Hughes JA, Sharrock WW. The Philosophy of Social Research. Longman (1997). Available online at:
    1. Lowe P, Phillipson J, Wilkinson K. Why social scientists should engage with natural scientists. Contemp Soc Sci. (2013) 8:207–22. 10.1080/21582041.2013.769617
    1. Marar Z. Why does social science have such a hard job explaining itself? | Education | The Guardian. The Guardian. (2013, April 8). Available online at:
    1. Jaffe K. Social and natural sciences differ in their strategies, adapted to work for knowledge landscapes. PLoS ONE. (2014) 9:e113901. 10.1371/journal.pone.0113901
    1. Kagawa Singer M, Dressler W, George S, Baquet CR, Bell RA, Burhansstipanov L, et al. . Culture: the missing link in health research. Soc Sci Med. (2016) 170:237–46. 10.1016/j.socscimed.2016.07.015
    1. Ford CL, Airhihenbuwa CO. Critical race theory, race equity, and public health: toward antiracism praxis. Am J Publ Health. (2010) 100:693–8. 10.2105/AJPH.2009.171058
    1. Foucault M, Gordon C. Power/Knowledge : Selected Interviews and Other Writings, 1972-1977. New York, NY: Pantheon Books; (1980).
    1. Bauman Z. Hermeneutics and Social Science. London: Routledge; (1978).
    1. Little D. What Is Hermeneutic Explanation? Dearborn, MI: (2008). Available online at: (accessed April 12, 2020).
    1. Linke R. Design Thinking, Explained. (2017). Available online at:
    1. Interaction Design Foundation (IDF) What is Design Thinking? Available online at: (2018).
    1. Lister C, Payne H, Hanson CL, Barnes MD, Davis SF, Manwaring T. The public health innovation model: merging private sector processes with public health strengths. Front Publ Health. (2017) 5:192. 10.3389/fpubh.2017.00192
    1. Stanton CR. Crossing methodological borders: decolonizing community-based participatory research. Qual. Inq. (2014) 20:573–83. 10.1177/1077800413505541

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere