Reducing social inequalities in health through action on settings : A conceptual framework

Background : Health promotion seeks to move beyond an individual-based approach to health to one focused on settings where people live, work and play. Through its focus on the interplay between personal, organizational and environmental determinants of health, the settings approach offers great potential to modify social determinants of health and influence social inequalities in health. The definition of the approach and exactly what constitutes a settings-based intervention remain debated. This limits the conduct of impact evaluations of such interventions and our understanding of their effect on health inequalities. Methods : A critical review of literature published in the last fifteen years on theoretical and practical bases of the settings approach will be conducted. Initiatives targeting health within various settings (eg. schools, workplaces, neighborhoods) will be analyzed. Results : A preliminary literature scan indicates that a variety of social health determinants including nutrition, physical activity and housing can be targeted within settings such as schools or neighborhoods. Few studies documented how subgroups within these settings responded to the intervention and how its effects were socially distributed across the population. A conceptual framework articulating the links between changes within settings and social health inequalities will be presented. Conclusions : Settings-based interventions can reduce social inequalities in health. Information on the distribution of effects across population subgroups would increase our understanding of interventions' impact on health inequalities. The proposed conceptual framework could serve as a guide to the development, implementation and evaluation of interventions aiming to tackle health inequalities by targeting settings.