Around 10 years after the creation of the WHO Commission on Social Determinants of Health (CSDH-WHO), and after some progress in studies on reducing health inequities, particularly in Europe, high indices of vulnerability and social inequity continue in certain social groups. This situation produces differentiated access to material and symbolic resources that impact the health of people and populations.1

In Latin American and other poor countries, there are peripheral urban territories marked by poverty, low education levels, unemployment or informal income generation, violence, insertion, high rates of abuse of alcohol and other drugs, disruption of social networks of support, and geographical and political exclusion. Africa has even the highest morbidity burden compared to other regions, and it also has the lowest per capita expenditure on health.1 Studies show how the poverty present in many people affects all life and health from birth and throughout the life course reducing life expectancy and increasing the chances of premature death in the most inequitable countries. Focusing on poverty is essential to Global Commission on the Social Determinants of Health.2–5Exclusion from or difficult access to income, work, education, housing, transportation and mobility, culture, leisure, a sustainable environment and social support networks cause of health inequities in poor countries. There are groups of people that suffer health problems and deaths, which are unfair and avoidable. 6,7

Studies have emphasised the strong recommendation of the CSDH-WHO in the construction of intersectoral policies to address health inequities. Intersectoral Action for Health is an important component of the Global Strategy for Health for All by the Year 2000 and a component of the 2006 “Health in All Policies” (HiAP). A HiAP approach promotes “effective and systematic action for the improvement of population health, using genuinely all available measures in all policy fields”.8 Intersectoral actions should occur at superstructural levels and be based on agreements between areas of government, i.e. all other sectors (economic, labour and employment, education, transportation, housing, environment, etc.) should elect health promotion as a priority, through global action aimed at reducing social inequities.9–13

Strategies focused in intersectoral policies are indisputable from the viewpoint of its urgency and necessity, but it is insufficient when considering the growth of social problems in urban territories in medium and large cities worldwide, especially cities in poor or developing countries.14 Therefore, in addition to these strategies from the central government of a country, it is necessary to include civil society in order to execute actions to reduce social inequities that affect the levels of health of the population, especially in the poorest territories.15

Thus, a scoping review was conducted with the general objective of determining the impact that intersectoral policies and social participation, implemented worldwide, have had on the modification of the social determinants of health and on the reduction of social inequities in health.

It is worth noting that there are studies referring to HiAP, including evaluation studies of the policies implemented in several countries, mainly in Europe1,6,14. However, few studies have shown intersectoral policies and community participation. So, this review could inform future intersectoral policies including successful experiences with the participation of civil society.

A scoping review is a review method characterised by researching the existing, relevant literature, which seeks to map and summarise a series of tests to convey the range and depth of a field supported in evidence-based practice. The scoping review method has six stages: 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data; 5) collating, summarising and reporting the results; and 6) consultation with interested individuals to inform or validate study results (optional).16

The current review was carried out from October to December 2015 and in the following stages:

• 1.

  Identifying the research question. The research question was identified as: “What policies or actions or strategies or programs, that include intersectoral actions and social participation focussing on the social determinants of health and reduction of social health inequities (SHI), which have been implemented worldwide, have shown modifications of these determinants and/or reduction of these inequities?”. In this work, intersectorality is understood as a policy and as a technical and administrative process that involves negotiation and the distribution of power, resources and capacities (technical and institutional) between different sectors. Intersectoral action is understood as not only the political intent of the government, but also managerial capacity, together with new institutional arrangements between different sectors of the administration to achieve results. Social participation is understood as organisational arrangements and practices that involve groups and organisations of civil society, particularly those that work with resource allocation for health needs.17

• 2.

  Identifying relevant studies. Databases were searched by pairs on PubMed and SciELO. The selection of these databases was due to the criterion of the search range, which allowed access to worldwide studies (PubMed) and Latin America (SciELO), thus recognising the importance of programmes and initiatives in Latin America on the SDH, through intersectoral strategies. The search period was from 2005 to 2015. This criterion was determined in line with the creation date of the CSDH-WHO in March 2005; this fact has been considered relevant for the development, by the countries, of policies and actions oriented to the modification of the social determinants of health as well as to the reduction of SHI. The search strategies applied to the databases are presented in Table 1.

  Table 1.

  Database search strategy.

  Descriptors for PubMed

  Search (cross-sectoral[All Fields] OR intersectoral[All Fields] OR (“policy”[MeSH Terms] OR “policy”[All Fields] OR “policies”[All Fields]) OR strategies[All Fields]) AND (“health inequalities”[All Fields] OR “health inequities”[All Fields] OR “health inequality”[All Fields] OR “health disparity”[All Fields] OR “health disparities”[All Fields] OR “socioeconomic health inequalities”[All Fields] OR “social health inequalities”[All Fields] “Healthcare disparities” OR “Health Disparities” OR “Social Health Inequalities” OR “Socioeconomic Inequalities in health” OR “social inequality in health”)

  Filters: Clinical Trial; Comparative Study; Evaluation Studies; Government Publications; Guideline; Multicenter Study; Observational Study; Practice Guideline; Review; Abstract; published in the last 10 years; English; Portuguese; Spanish; Time period: 2005- 2015.

  Descriptors for SciELO

  (cross-sectoral OR intersectoral OR policy OR policies OR strategies) AND (health inequalities OR health inequities OR health inequality OR health disparity OR health disparities OR socioeconomic health inequalities).

  Filters: Time period: 2005- 2015. Language: English, Spanish or Portuguese.
• 3.

  Study selection. The studies were selected according to an analysis of the title, followed by an analysis of the abstract and, finally, a thorough analysis of the content, conducted in two stages a full reading of documents by each reviewer on independent way and then by pair. Documents focused on the research question (intersectoral actions and social participation focussing on the social determinants of health and reduction of social health inequities) were included. Documents that did not show results in the modification of SDH and/or in the reduction of SHI were excluded.

• 4.

  Charting the data. The documents selected were analysed as proposed by Andrade et al.17 for intersectoral action, as defined in Stage 1. In accordance with this conceptual framework, the following variables were defined:

  • •

    Intersectoral action (IA):

  • IA-A: Creation of ministries focused on specific problems; e.g. social development, urban development, gender equality, poverty reduction, among others. As well as intersectoral policy created by Decree of the federal government.

  • IA-B: Central government initiatives to address social emergencies, such as drug use, violence, etc., which combine the participation of local authorities and civil society organisations, associations and groups, as well as mobilisation and decision-making, providing more flexibility for governance.

  • •

    Social Participation (SP):

  • SP-A: social participation that integrates with the system of governance,

  • SP-B: ombudsmen and public defenders,

  • SP-C: corporate councils,

  • SP-D: associations of users of services in dialogue with governments.

• 5.

  Collating, summarising and reporting the results. This work used the SDH model of the CSDH-WHO1,10,11,18–20 as a conceptual and theoretical framework, as well as the theoretical constructs of social capital (SC)21,22 and the life course (LC).23,24

The SDH model is defined in two spheres: structural and intermediate determinants. Structural determinants are those linked to social stratification and include socioeconomic and political contexts and distribution of power and resources, as well as labour market, gender, ethnicity, social class and education level. Intermediate determinants include: a) material circumstances, such as housing, income level, working conditions or neighborhood; b) psychosocial circumstances, such as lack of social support, stressful situations (negative life events), poor control, etc.; c) behavioral and biological factors, such as life-threatening lifestyles; and d) the health system.1,10,11,18–20Social capital is a theoretical construct developed by Macinko and Starfield21, and Kawaschi et al.22, who took the concept social capital from contributions by thinkers like Robert Putnam, James Coleman and Pierre Bourdieu, and applied in the field of health and more specifically in the field of studies on social determinants of health. The social capital is defined as a specific form of social organisation in which a strong network of interpersonal relationships is based on reciprocity and social cooperation. This organisation produces a personal and collective development capital that determines development in all sectors: economic, cultural, political, social and health.21,22

The theoretical construct of life course understands that the socioeconomic inequities present in certain regions have a lifelong effect on people born and raised in these regions. Thus, life course epidemiology is defined as the study of long-term effects on health or disease risk of physical or social exposures during gestation, childhood, adolescence, young adulthood and later adult life.23,24

The documents were then compared according to the variables and theoretical frameworks and the results achieved in practice concerning the SDH and the reduction in health inequities in their regions. Likewise, we sought to analyse the implications of these studies for current research and our results.

The process described collected 2734 documents from the PubMed database and after excluding duplicates and applying filters referring to the design of the studies to be reviewed, 599 documents remained. Further selection based on titles and abstracts reduced this to 78 documents. After full reading, remained 23 documents to be reviewed. Regarding the SciELO database, 1872 documents were initially collected. After applying filters, excluding duplicates and analysing the titles, 89 documents remained. After reading the abstracts, 64 documents were selected, of which 22 were selected for review following in-depth reading. Therefore, 45 documents with the potential for final selection for review were selected. After re-reading and preliminary analysis of the results in pairs and independently, 26 documents were excluded for not being a research (n = 18, 69.2%), and not showing impacts on SDH and/or SHI (n = 8, 30.8%.) Thus, 19 documents were selected. However, one document was included by expert criteria, constituting the final sample of 20 (Fig. 1).

Figure 1.

Selection chart of documents for review.

(0.17MB).

Concerning the year of publication, five studies were from 2015, four from 2014, two from 2013, two from 2012, two from 2011, one from 2010, two from 2009, one from 2008 and one from 2006. According to geographical distribution, two were in Europe context, two in Latin America context, one in Africa, one in Americas and three in Australia. Other were developed in specific countries: three of the studies were developed in Brazil, one in Cuba, one in Mexico, two in Canada, three in the United States and one in Venezuela. The range of studies involved regions or continents, such as Americas, Latin America, Europe and Australia as well as cities of a certain region or country, or the national contexts of certain countries. Other contexts included territorial communities (neighbourhoods and/or regions) or group communities (ethnic, gender) in a given state or city of a given country. Concerning the study design, there were six case studies, three review studies/documental analysis, six qualitative research studies (three ethnographic studies, two participatory action research studies and one qualitative evaluation study), three evaluation studies, one longitudinal ecological study and one randomised controlled trial (Table 2).

According to analysis of intersectoral action and social participation, the studies indicated the creation of ministries and mergers between health departments and other sectors of public administration, including social assistance, education, environment, with a view to reducing health inequities and intersectoral policy created by decree of the federal government (IA category A). Government programmes focused on emergency issues like hunger, epidemics, infant mortality and malnutrition, and diseases (IA category B) were also identified. The analysis also indicated that intersectoral actions were conducted in combination with strong community participation (SP categories A, B, C and D).

According to the variables, 12 documents reported intersectoral action associated with social participation SP, in any of their categories.17,25–35Four documents reported local community-based social participation actions in partnership with different institutions.35–38 Three documents referred exclusively to intersectoral action conducted only by central government policies, without community participation39,42,43 (Table 2).

Regarding their theoretical frameworks, eight documents reported on intersectoral actions and social participation pertaining to CSDH and SC.25,26,30–35 Three documents showed the actions taken were included in all three (CSDH, SC, LC).17,27,28 Two documents showed actions inserted within SC.36,40 One included the CSDH and LC.41 And five only included references to the CSDH29,38,39,42,43 (Table 2).

In relation to the reduction in SHI, studies showed numerous improvements, including: increased access to health and education; follow-up of pregnant women and increase in prenatal examinations; reduction in malnutrition and child mortality; reduction in extreme poverty and hunger; a reduction in epidemics;17,28,30,32,35–38,41 reduction in infectious diseases, such as tuberculosis;39,41 control of problematic use of alcohol and other drugs;36,37 promotion of health and mental health and improvements in health care and mental health;36,37,40,43 environmental improvements and basic sanitation in vulnerable regions;37 creation of healthy habits among populations and social groups;38 increasing in social capital; increasing in social protection and access to healthcare for vulnerable population, reduction of violence and creation of safer areas.25,27,28,32,37,41

Other works revealed: increasing in health promotion actions and physical activities;24 decreasing in cardiovascular risk factors; renovation of physical areas in neighbourhoods to facilitate access to services; increasing in the number of day care centres providing high-quality care to children; increasing in access to healthy food; prevention of HIV transmission between mother and child and reducing noncommunicable diseases; installation of central heating systems to increase health status and quality of life in vulnerable neighbourhoods.28,30,31,35,37,39,41

Other authors showed up socioeconomic improvements, increasing in access to education and other social services, accessing to healthy food, decreasing in barriers to gender, reduction of extreme poverty and employment generation.28,33,34,37,41,43

Finally, other studies tackled SDH such as creation of agendas for confronting racism, promoting actions that improved social capital, education, transportation, employment, food access, housing, environmental exposure and access to healthcare services.30,42,43

Reflecting on our research question, the results of the review showed that the intersectoral and social participation experiences studied yielded positive outcomes regarding health status and quality of life in the communities, countries or regions in which such experiences were implemented.

According to the variables of this research, there is a prevalence of studies on intersectoral actions developed together with community participation (nongovernmental social organizations and civil society), which add up to 12 documents from the 20 analyzed.17,25–35 This recommendation is particularly emphasized in some of the reviewed studies17,37–40 and also by studies that do not address specific intersectoral actions but underline the need for intersectoral strategies to be necessarily accompanied by social participation (local decision-makers and community membership).6,44–46 It is interesting to note that four studies36–40 presented territorial intersectoral strategies in areas in neighbourhoods, which did not originate from central government policies, but were the result of the local community organization and stakeholders. These studies based their analysis on the argument that strong cohesion and production of a social capital, in addition to economic improvements, is very important for reducing social inequities in certain areas, especially when problems involve violence, poverty and security.20,40,47,48

Although intersectorality is denoted as essential to obtain good results from the policies implemented, the studies indicate that important administrative and managerial difficulties need to be overcome. The problems highlighted concern difficulties in surmounting a prevailing sectoral logic that makes cooperation, distribution of responsibilities and operational actions unfeasible. Moreover, difficulties related to governments promoting the decentralisation of power and deliberative capacity to intersectoral forums and obstacles to civil society organising itself in a cohesive manner to claim its rights to increased political power, are important factors.17,26,45,49

Andrade et al.17 presented as a complication in the implementation of intersectoral projects, the fact of the technical unpreparedness of managers. The need to create a cooperative culture in management and administrative relationships, together with technical training for intersectoral management, is fundamental.

According to our theoretical framework, eight documents reported on intersectoral actions and social participation using as theoretical reference of the SDH model of the CSDH-WHO associated with the social capital. 25,26,30–35 This data can be interpreted by associating the result referring to the variables, that is, the studies strongly emphasized the need to develop intersectoral actions associated with social participation and the importance of besides the economic social determinants also to strengthen the social bonds of the community involved in the project.

According to reduction in social health inequities, studies reviewed showed improvements in the following main areas: increased access to health services, increase in prenatal examinations, reduction in malnutrition and child mortality, prevention and reduction communicable and noncommunicable diseases, reduction in epidemics, prevention on HIV transmission, decrease in cardiovascular risk factors, increase access to healthy food. Positive results were also presented: increasing in access to education, transportation, housing, healthy environment, reduction of violence and creation of safer areas, reduction of poverty, socioeconomics improvements, decreased barriers to gender, employment, increase of social capital, etc.17,26–42 So according to the studies the overall results were positive and many advances in relation to the social determinants of health can be observed.50,51

Although advances can be verified in many countries, social inequities are still predominant factors marking health inequities and obstacles to the establishment of equity.17,28,34,36,42 In poor countries, policies that address the social determinants of health and the reduction of inequities are fragmented and show discontinuity in their implementation, management and inspection. Local governments show important differences in the pace and demarcation of priorities with which policies are implemented, creating gaps between regions in the same country.52,53 Concerning Latin American countries, there are problems related to strong cultural, ethnic and gender issues, and poverty which need to be addressed in order to implement intersectoral projects aimed at producing health equity.2,17

Although studies show that important SDH policies in Europe have been successfully implemented there are significant disparities between Eastern and Western Europe. Eastern European countries present health problems and inequities in health access that are as severe as the world's poorest countries.4,6,26,52 Similar to Eastern Europe, other studies reiterate that Iberian countries have high rates of health inequities.13,18,45,52–54It is interesting to note that all the documents initially collected had titles containing the central theme of the social determinants of health, social inequities and mentioned or recommended intersectorality as a coping strategy. However, only 20 documents focused directly on policies, strategies and/or actions that concretely applied intersectoral programmes focused on the social determinants of health and were combined with social participation. This observation is reinforced by the work of Pons-Vigués et al.39, which emphasizes the current tendency of an increase in academic-scientific productions on this subject, while countries still face enormous difficulties in achieving intersectoral experiences. This is due to the strong impregnation of the anachronistic logics of state and governance management, fragmented and cemented in sectorial interests, as well as the highly centralised manifestation of political power in national governments, without the necessary decentralisation of power to local governments and civil society. These observations were also mentioned by other studies.55,56

Results from the intersectoral experiences reported in the studies reviewed herein show significant advances in reducing health inequities, increasing access to services and improving the quality of life for the groups and populations involved.

Future studies are required to deepen new diagnoses on the subjects researched and to strengthen the strategies that aim to transform the forms of global governance in various localities across the planet towards social equity and health.

One limitation of this research is the range of studies reviewed; expansion of the search strategies in other databases is important so that studies in other regions of the planet can be analysed. The revised documents are predominantly derived from research developed in countries of the Western world. In addition, the literature evaluating or describing the impact of intersectoral actions on health is limited, something that has been observed by other review studies.15,51

This paper was an important initial step towards a deeper study of the theme investigated. In line with the WHO's objectives of eradicating global poverty by 2050, aimed at global health equity, global multi-sectoral, intersectoral and transnational cooperation actions will be increasingly needed. Therefore, studies like this and additional evidence are needed to show that intersectoral policies and/or combined with social participation can have an impact on the social determinants of health and on reducing social and health inequities.

The studies showed significant health outcomes and advanced in reduction social inequities. On the other hand, they also showed that enormous obstacles stand in the way of equity, participation and the expansion of democratic management objectives. Social mobilization is needed in the search for empowerment in the implementation of equitable social policies and more democratic and more participatory forms of governance, together with greater technical capacity in the exercise of intersectoral management.

Clara Bermúdez-Tamayo.

R.C. Fiorati developed the research, data collection and analysis and elaborated the manuscript. P. Serrano Gallardo guided the study, developed the research, data collection and analysis and elaborated the manuscript. J. Segura del Pozo, M. Ramasco Gutiérrez and R. Alexandre Arcêncio participated in the analysis of the data, reviewed the successive manuscripts and the final version.

This work was supported by the São Paulo Research Foundation (FAPESP), Brazil, under grant no. 2015/00746-8.

None.