Opinión y análisis / Opinion and analysis

Recent efforts to generate an international consensus Synergy for on addressing the social determinants of health (SDH) (1) present a timely opportunity to integrate—theoreti- equity: integrating health cally, politically, and practically—social determinants and (HP) frameworks for promoting promotion and social health and health equity. Drawing on our work in the Americas, this paper aims to identify the potential determinants of health synergies between these two approaches, as well as the challenges inherent to such an integration. approaches in and HP was launched in 1986, with a widely sup- ported definition and framework for action, and has beyond the Americas growing evidence of effectiveness (2, 3). The SDH framework builds on the legacy of HP, particularly HP’s role in health care systems, and more recently, Suzanne F. Jackson,1 as articulated in the Health in All Policies (HiAP) ap- proach (4–6). Yet, arguably, the SDH community has 2 Anne-Emanuelle Birn, made inadequate use of HP concepts and methods; Stephen B. Fawcett,3 and, conversely, much of the HP community has not actively embraced SDH efforts. Advocates of HP, as 1 3 Blake Poland, and Jerry A. Schultz originally conceptualized, have more than 25 years of experience working at multiple levels and in mul- Suggested citation: Jackson SF, Birn A-E, Fawcett SB, Poland tiple sectors, using a variety of strategies to address B, Schultz JA. Synergy for health equity: integrating health pro- inequalities in power and resources (7). Yet in many set- motion and social determinants of health approaches in and be- tings, social justice-oriented HP approaches have been yond the Americas. Rev Panam Salud Publica. 2013;34(6):473–80. overshadowed and distorted by individually-focused lifestyle and behavior change strategies. In addition, evaluation of collective action and social/political HP synopsis interventions has proven challenging (8, 9). SDH, by Health promotion and social determinants of health approaches, contrast, has a strong epidemiological rationale for when integrated, can better contribute to understanding understanding the impact of inequality on health and and addressing health inequities. Yet, they have typically well-being and focuses on the role of policy in reducing been pursued as two solitudes. This paper presents the key inequality. At the same time, the HP’s identification of elements, principles, actions, and potential synergies of these how inequalities in power and resources are produced complementary frameworks for addressing health equity. The and reproduced, and notably who and what entities are value-added of integrating these two approaches is illustrated implicated in these processes, have not been sufficiently by three examples drawn from the authors’ experiences in the taken up by mainstream SDH approaches (10–12). Americas: at the community level, through a community- Given the potential of each approach to improve based coalition for reducing chronic disease disparities among health equity, we suggest that further integrating HP minorities in an urban center in the United States; at the and SDH may prove synergistic. Activities in Latin national level, through healthy-settings interventions in America are especially illustrative of such synergies Canada; and at the Regional level, through health cooperation (13, 14). Here we draw on three examples of work in based on social justice values in Latin America. Challenges the Americas to bolster this argument. Table 1 outlines to integrating health promotion and social determinants of the background, principles, approaches, and chal- health approaches in the Americas are also discussed. lenges related to HP and to SDH, and the synergistic Key words: health promotion; health inequalities; potential of integrating them, including implications health planning guidelines; health vulnerability; social for harmonized action. We conclude with some key policy; urban health; Americas. messages about the future value of integrating these approaches, particularly for the World Health Organi- 1 Dalla Lana School of , University of Toronto, Toronto, zation and its Regional offices. Ontario, Canada. Send correspondence to Suzanne F. Jackson, email: [email protected] 2 Centre for Critical Development Studies Office, University of To- HEALTH PROMOTION ronto Scarborough, Ontario, Canada. 3 Work Group for Community Health and Development, Applied Behavioral Science, University of Kansas, Lawrence, Kansas, United The health promotion approach emerged in States of America. the wake of the pivotal 1978 Alma-Ata Conference

Rev Panam Salud Publica 34(6), 2013 473 Opinion and analysis Jackson et al. • Integrating health promotion and social determinants of health approaches

TABLE 1. Comparison of principles and actions associated with Health Promotion (HP) and Social Determinants of Health (SDH)

Topic HP SDH Potential for synergistic effects World Health Organization • WHO-sponsored Ottawa Charter • The WHO Commission on SDH • WHO and its Regional Offices could (WHO) involvement & major (1986) generated consistent (CSDH) produced its final report, combine their support and initiatives source documents definitions and concepts used “Closing the gap in a generation: for HP and SDH into a single unit/ around the world, and related Health equity through action on effort and expand resources and (WHA) SDH” (2008) reach of both. resolutions • Rio Political Declaration on SDH • Could develop a single summary • WHO Global HP Conference (2011) at the WHO Conference document (and related tools) useful series resulting in a set of on SDH in Rio de Janeiro and to grassroots and social movements declarations and charters 1988, WHA resolutions related to both so HP and SDH strategies can be 1991, 1997, 2000, 2005, 2009, used together to advance the equity 2013 agenda

Core From the Bangkok Charter for HP in From CSDH’s, “Closing the Gap” • Integrate core recommendations recommendations a Globalized World (2005)— final report (2008)— of both HP and SDH and show concrete evidence and examples Make promotion of health: Improve daily living conditions by: of mutual interventions/actions, in (a) central to global development (a) tackling the inequitable particular settings at local, municipal, agenda distribution of power, money, national and international levels (b) a core responsibility of all and resources governments (b) measuring and understanding (c) a key focus of communities and the problem and assessing the civil society impact of action (d) a requirement of good corporate practices

Principles/values • Positive definition of health as • Social justice: ensuring that all • Be more explicit about who and what more than just the absence of have what is needed for health is driving inequality at all levels from disease (WHO, 1948) and wellbeing local to international through use • Broad set of prerequisites for • Participation: meaningful and of political economy frameworks of health that include all SDH equitable participation and control analysis • Primary focus on participation in decision making; including • Advocate for —and and empowerment via engaging those oppressed and subject to the conditions that ensure it—as a people in shaping the factors social, economic and/or political human right that affect their health, through: exclusion. • Recognize and appreciate participatory planning and • Empowerment: process through indigenous cultures and traditional decisionmaking processes; and which people act collectively to ways based on human rights collaboration among community gain greater influence and control principles members, social movements, and over the determinants of health • Go beyond formulaic/legislated nongovernmental organizations and wellbeing in their community public consultation to ensure (NGOs) to influence governments and society meaningful and equitable and corporate sectors to change participation and control in decision policies and sociopolitical making and agenda setting structures among all groups; including those oppressed and subject to social, economic, and/or political exclusion

Entry points for intervention • Individual • Society/population level/ all levels • Comprehensive interventions—in • Family/household of policymaking/ through the life multiple settings and at all levels, • Community course from local to global—that reduce • Organizations/corporations/ • Focus on specific vulnerable differential and unjust exposures, workplaces populations (socially-excluded, susceptibilities, and consequences • Health services disadvantaged groups) for socially excluded / disadvantaged • Settings such as schools, • Global health, development, groups municipalities, islands economic, and social policy • Efforts across different sectors, • Society/populations agenda-setting fora levels of government, including • Global development entities the corporate sector. Taking into account their contribution to health and health (in) equity • Focus on environment/ climate change at multiple levels • Collaborate with social movements to advocate for change in policies at multiple levels and across sectors

(Continues)

474 Rev Panam Salud Publica 34(6), 2013 Jackson et al. • Integrating health promotion and social determinants of health approaches Opinion and analysis

TABLE 1. Continued

Topic HP SDH Potential for synergistic effects Strategies • Building healthy public policy, • Health in All Policies • Health in All Policies intersectoralism, Health in • Mechanisms of social protection • Enhance community control of All Policies, using whole of through the lifecourse (e.g., health promotion/social determinants government approach policies and programs that initiatives (e.g., listening to and • Creating supportive environments improve housing and reduce starting with the voices and through changing social norms discrimination, economic aspirations of the community in and public support for change insecurity, hazards, and harsh planning and action) • Strengthening community action living conditions) • Ensure sustainable structures for and community participation in • Redistributive policies (e.g., people to work together across decisionmaking that ensure adequate financial sectors, settings, and multiple levels • Developing personal skills and resources for all children and • Establish sustainable financing capacity-building families) mechanisms that ensure a • Re-orienting health services to • Universal access to education coordinated, integrated and holistic focus on Strengthen occupational health response to community-determined (including health promotion and safety and health protection and goals disease prevention) their oversight • Enhance capacity among community • Promote and strengthen universal members for implementing effective access to health and social and appropriate equitable health services promotion interventions in diverse • Build, strengthen and maintain contexts public health capacity, including • Reverse current bias towards capacity for intersectoral action, large-scale and unsustainable on social determinants of health practices (e.g. subsidies/preferential legislation for extractive industries; outdated building codes) State of evidence • Some evidence of impact of policy • Strong evidence of associations • Gather narrative stories and change between health inequities empirical evidence about how • Individual behavior change and SDH (i.e., socioeconomic communities participate in creating interventions require other position, social class, gender, conditions for improved health and strategies (e.g. policy, community race/ethnicity, education, health equity engagement) for success occupation, income) • Long-term, socially grounded • Weak evidence of impact of • Limited evidence of what works analyses of what makes for healthy community action interventions. (and under what conditions) in societies And multi-sector, multi-level affecting social determinants • Stronger emphasis on links collaborations need more and associated improvements in between human and ecosystem research health equity health Challenges • Going beyond the national • Addressing contradictions of • Addressing large structural issues, contexts to introduce health market capitalism and global e.g., resource depletion, climate promoting policies at the global financial and trade regimes change, extensive ecosystem level degradation, social and economic inequality • Getting health concerns into international development, economic, and trade talks, treaties, regulations, and practices

on Primary Health Care, which sought to replace also emphasized empowerment, collaboration, and the existing top-down technical approach to disease public participation in decisionmaking (18, 19). Of the control with a more explicitly political understand- five Ottawa Charter strategies, three focus on creat- ing of health to be achieved “in the spirit of social ing broader changes in social, political, and economic justice”(15). The Ottawa Charter for Health Promo- environments through policy change, advocacy, and tion (16) aimed to operationalize the Alma-Ata prin- community action. ciples with five main strategies for health promotion Over the past quarter century, a range of HP (see Table 1). The Ottawa Charter also listed a set actions have been implemented across the world, of prerequisites for health, including peace, educa- including at the global level with the Framework tion, income, a stable ecosystem, social justice, and Convention for Tobacco Control (20), using public equity, which were expanded in the Bangkok Charter policies, collaborative strategies, and community ac- for Global Health Promotion in 2005 (17). Akin to tions. Nonetheless, the bulk of interventions have SDH approaches, the Bangkok Charter recognized focused on changing individual behavior (3), even inequalities within and between countries related to as some have targeted social well-being, and politi- environmental degradation, urbanization, and global- cal, environmental, and community-level efforts and ization. As reinforced in the Nairobi Declaration, HP outcomes (11, 21).

Rev Panam Salud Publica 34(6), 2013 475 Opinion and analysis Jackson et al. • Integrating health promotion and social determinants of health approaches

A key HP strategy is the settings approach multiple settings and sectors, at different levels, with (e.g., Healthy Schools, Healthy Cities/Communities, the democratic participation of stakeholders, and us- Healthy Workplaces), which involves multiple sec- ing multiple entry points to address inequity. Unlike tors and levels—from individual to collective and narrowly targeted programs that often stigmatize the policy—in efforts to change the forces that produce most oppressed populations, a synergized HP-SDH and reproduce inequities in health and well-being strategy would embed particularistic efforts within (22). Central to the settings approach is collaboration universal policies to generate solidarity, rather than and participatory work undertaken to address condi- divisiveness. The following three examples drawn tions for health within the setting, as well as coordina- from our work at the community, national, and Re- tion across settings (23, 24). gional levels illustrate the kinds of HP-SDH synergies already in practice in the Region of the Americas. SOCIAL DETERMINANTS OF HEALTH CASE STUDIES The conceptual framework for action on social determinants developed by the World Health Organi- Case 1. Community-level action: a zation (WHO) Commission on SDH (25, 26) outlines community-based coalition to reduce chronic three levels of determinants that interact to affect disease disparities affecting African-Americans equity in health and well-being: (a) structural driv- ers (e.g., macroeconomic, social, labor, taxation, and As in other parts of the Americas, widespread environmental protections and policies; governance; inequalities in chronic diseases particularly jeopardize societal norms and values); (b) social position and the health of racial/ethnic minorities in the United stratification determinants (i.e., social class, gender, States, a function of a long history of societal discrimi- race/ethnicity, education, occupation, and income); nation and oppression leading to increased exposure and (c) intermediary determinants (e.g., material cir- and susceptibility to unhealthy conditions, more se- cumstances, behaviors, and biological factors; psycho- vere consequences, and greater barriers to overcoming social factors; health care system) (4). This framework these unjust conditions (27). The Kansas City–Chronic also postulates three mechanisms by which health Disease Coalition began in 2001 and worked for nearly inequities are produced: (a) differential exposure to in- a decade to modify exposures to health-promoting termediary factors (e.g., poor material circumstances, conditions and reduce vulnerability to diabetes and such as inadequate housing, hazards, and harsh living cardiovascular diseases (CVD) among African Ameri- conditions); (b) differential vulnerability to health-­ cans in Kansas City, Missouri (28, 29). Funded by the compromising conditions (e.g., ill health, disability); United States Centers for Disease Control and Preven- and (c) differential consequences (e.g., differential tion’s Racial and Ethnic Approaches to Community harm associated with having a health condition, such Health (REACH) 2010 initiative, the Coalition engaged as that experienced by socially-excluded groups with community and scientific partners in changing contex- limited access to quality health services). tual factors related to healthy and physical However, none of these determinants and mech- activity in low-income neighborhoods. The Coali- anisms explicitly names the marked increase in con- tion sought to address particular social determinants centration of wealth and power by financial elites, or linked to health inequities, including enhanced expo- the accelerated ecological destruction caused by over- sure to health-promoting conditions (e.g., expanded emphasis on economic growth and consumerism— walking groups) for low-income ethnic and minority both of which have very real material consequences groups and improving community-level abilities to and could be seen as the “causes of the ‘causes of the respond (e.g., building the community’s capacity to causes’” (12). It is especially in this context that Table 1 change policies and conditions at the local level). may prove useful. It begins by showing the many sim- The Coalition used a community-based par- ilarities between HP and SDH. For example, both pay ticipatory approach referred to as the Health for attention to policies and socio-political structures that All model, that consisted of several components: affect health. Both embrace participatory approaches (a) community-determined vision and mission that to decisionmaking. And both are concerned with social focused on reducing racial disparities in CVD and justice and equity. HP is particularly concerned with diabetes; (b) a locally-developed logic model to guide focusing on many levels, from individual to policy, planning, implementation, and evaluation; (c) an ac- and offers much wisdom about working in settings, tion plan that specified particular changes (e.g., an taking advantage of active social and public-interest expanded program or modified policy) to be sought civil society movements, and community action. SDH in multiple sectors, with delegated responsibilities and offers a strong epidemiological basis for equity, pays timeline; (d) mini-grants to ensure community-led im- special attention to the most vulnerable populations, plementation of planned community/system changes; focuses on the life course, and emphasizes policy and (e) community mobilization; (f) technical assistance to social change as the key forms of action. develop coalition capacities; and (g) documentation Synergies between HP and SDH could be and systematic reflection on progress to guide ongo- achieved by deploying comprehensive approaches in ing improvement.

476 Rev Panam Salud Publica 34(6), 2013 Jackson et al. • Integrating health promotion and social determinants of health approaches Opinion and analysis

With the collaboration of over 20 partner orga- ventions had been evaluated, and if so, how and what nizations from multiple sectors, including faith orga- the results were; and key issues raised by the authors. nizations, health care providers, health departments, While many initiatives were evaluated, only eight human services, media, neighborhood networks, the included specific attention to the program’s impact on private sector, schools/education, and worksites dur- reducing inequities. ing a 6-year period, the Coalition implemented 655 Four elements emerged as central to an equity- new programs, policies, and practices in the commu- focused settings approach: a) an explicit focus on SDH; nity that changed the local environment in which the b) addressing the needs of marginalized groups; c) ef- residents lived. For example, access to healthy foods fecting change in a setting’s structure; and d) mean- was modified and its changes were associated with ingfully involving stakeholders. Each came with a statistically significant increase in the percentage of related challenges. Drawing on complexity theory, African-American adults in the community reporting critical realism, and community development theory daily consumption of five or more servings of fruits and practice, the authors proposed a model for “set- and vegetables. tings praxis” that takes into account social context and This case illustrates several important aspects the ways that inequities are produced and reproduced of integrating HP and SDH, particularly the use of through interpersonal and institutional practices, as comprehensive interventions at multiple HP levels— well as broader labor/taxation/environmental poli- individual, community, and organization—strategies cies that build on local strengths/capacities and gener- of community action, policy development, and inter- ate resilience (32, 35, 36). sectoral collaboration to change conditions related This example illustrates the synergy of HP and to health and well-being among groups that have SDH via attention to disadvantaged groups and struc- historically experienced health inequities. It also il- tural change. When examining many cases, one can lustrates central SDH approaches, e.g., focusing on see the broader universal policy strategy (affecting so- socially-­oppressed groups as an entry point, and then cial structures, such as labor law and taxation), and an employing community-determined strategies, such as emphasis on working with and addressing the needs addressing structural impediments, capacity-building, of marginalized groups. and policy change. Another element of synergy is the extent to which involvement in these activities en- Case 3. Regional-level action: South-South hances political interest and engagement that in turn cooperation based on social justice values influence the structural determinants of health. Another way to consider integrating HP and Case 2. National-level action: Healthy settings SDH is through country-to-country and Region-wide approach in Canada approaches to health. Amidst enormous diversity, the countries of Latin America share histories of colonial- Creation of supportive environments for health ism, unstable governments, repressive and authoritar- is a basic action principle of health promotion, and ian regimes, and neoliberalism. Yet progressive soli- equity is a core value. A settings approach offers an darity has periodically and repeatedly materialized. opportunity to bridge these two, with its focus on Activists, advocates, and professionals have devel- the interplay among individual, environmental, and oped common health-enhancing policies, beginning SDH. The settings approach aims to influence health in the 1890s with improving housing/sanitation and through action on “the places or social contexts in increasing access to education, and later, in the 1920s which people engage in daily activities, in which and 1930s, building social security systems (37)—all environmental, organizational, and personal factors of which were facilitated by Americas-wide meetings interact to affect health and well-being” (30), as well and exchanges. as with people in those settings. Despite the challenges A case in point is the rights approach to child of evaluating this kind of work (31), evidence of the health developed in Uruguay and formalized by its effectiveness of the settings approach is mounting, Children’s Code of Rights of 1934, which served as especially as a strategy to explicitly tackle health ineq- a reference point for the entire Region and beyond. uities (32–34). After grappling with decades of stagnating infant In 2009, the Public Health Agency of Canada set mortality despite a variety of public health measures, up a Settings Approach Working Group comprised Uruguay’s passage of a Children’s Code marked of members of the academic, government, and health one of the world’s most comprehensive mother and sectors. The group conducted a scoping review of child social protection policies, delineating the judicial the literature to determine what evidence existed for and administrative basis for the state’s protection of a settings approach to reduce health inequities and children from the prenatal period to adulthood in what lessons had been learned from this work (35). the areas of health, education, legal tutelage (of ‘de- Thirty-five articles concerning 20 different initiatives linquents’ and abandoned children), nutrition, hous- were critically analyzed regarding the following: ing, social services, work (for adolescents), and other objective(s); type(s) of settings targeted; what was elements of well-being. Uruguay quickly shared its acted on and how; who was involved; whether inter- model with other Latin American countries, using the

Rev Panam Salud Publica 34(6), 2013 477 Opinion and analysis Jackson et al. • Integrating health promotion and social determinants of health approaches

Montevideo-based International American Institute fide engagement of public-interest civil society within for the Protection of Childhood, founded in 1927, as government decisionmaking in order to reform, or a vehicle for setting standards, advising on legislation even, revolutionize policies and practices that other­ and institutional development, and interchanging ex- wise produce and reproduce social inequity. With periences across the Americas and beyond (38). respect to entry points (Table 1), SDH starts with en- More recently in Latin America, a confluence gagement and solidarity with vulnerable populations, of populist and left-wing parties has been elected in socioeconomic policies, and national/global fora for countries as diverse as Argentina and El Salvador. action. The main contribution of HP here is using set- These parties have run on platforms that emphasize tings as a point of entry. Both strive to work across all social redistribution, welfare-regime building, and levels with multiple sectors. All three cases illustrated social rights (39). Coupled with economic growth in the integration of social structural policy change in set- certain large middle-income countries, such as Brazil tings as a route to health equity. and Venezuela, these political shifts have enabled The challenges to this integrated approach arise development of solidarity-based forms of South- principally from the political nature of these actions, South cooperation, challenging the traditional, self- especially for the large health promotion practitioner interested geopolitical-economic forces propelling this workforce. A combined HP-SDH approach would fo- field. These alternative forms of health diplomacy cus on policy and socioenvironmental change, politics do not dictate the terms of health and development of redistribution, actions around sustainability of the cooperation, but rather respond to political demands ecosystem, social justice approaches to societal de- for greater equity and draw from local participatory velopment, and collaboration within civil society (4). democracy, all building on HP and SDH approaches However, a focus on individual lifestyle remains ap- in areas such as universal comprehensive primary pealing to dominant political players because it does health care. Key players include the Union of South not “rock the boat” or focus on changing the underly- American Nations (UNASUR) and nation-nation ef- ing conditions and processes of unequal power and forts, such as Cuba’s half-century of cooperative resources that generate differential exposures and sus- health solidarity in Latin America and beyond, and ceptibilities to ill health. It fits with a medical model more recently, Brazilian cooperation in Latin America and has an established system of generating evidence. and Lusophone countries (40–42). By contrast, an integrated HP-SDH approach is A further contemporary development from a fundamentally political and social change-oriented Latin America brings us back to HP’s healthy set- endeavor that challenges the existing (and historical) tings strategy: locally-based movements, such as the distribution of power and resources. We believe it is indigenous “Buen Vivir” approach, questions and essential that these efforts operate at multiple levels reframes conventional assumptions about “growth” and sectors and engage communities in connecting lo- and “development” and their links to well-being, cal issues to global concerns; for example, by connect- instead calling for a new paradigm of “living well” ing local poverty and lack of livable wages with na- within existing resources and in harmony with the tional and international trade policies. The synergies natural environment. These efforts have circulated in come particularly through intentional and multi-level the Region, moving from the local to the national, and collaborative efforts—at local, national, and interna- are now enshrined in the Constitutions of Bolivia and tional levels. Promising aspects of a synergistic agenda Ecuador (43, 44). include investing in poverty alleviation (or wealth This case study illustrates the value of SDH en- redistribution), financial reform to limit the concen- try points into social policy agenda setting and using tration of wealth, community-oriented and publicly SDH strategies for social protection, redistributive pol- funded primary health care, legislation to reduce envi- icies, and universal access to health and social services ronmental degradation and promote food security, lo- (Table 1). How effectively these large-scale structural cal community economic development, and fostering efforts meet the quotidian challenges of community community participation and empowerment. and settings-level health promotion—including Buen Decades of experience with HP approaches has Vivir—will be a central determinant of their long-term much to teach us about methods for collaborative success. action to improve health equity, and there is a large workforce globally interested in advocating for this SYNERGIES BETWEEN HP AND SDH agenda. Both HP and SDH discourses have been sub- ject to selective uptake and dismissal. In both cases, We have argued that to date, HP and SDH ap- the crucial issue is willingness to name who/what is proaches have not made sufficient mutual use of each responsible for the production and reproduction of other’s principles and strategies. Yet, all three case inequities over time, and recognizing the inherently examples presented here show potential for or actual political nature of, and long-term commitment to, synergies. In terms of the principles and values shown social change required for equitable health promotion in Table 1, HP and SDH share a belief in principles of and protection. Latin America, far more than North social justice and empowerment. Both value public America under the current political conditions, has participation in policy formulation and promote bona become a leader in moving such an agenda forward.

478 Rev Panam Salud Publica 34(6), 2013 Jackson et al. • Integrating health promotion and social determinants of health approaches Opinion and analysis

Looking into the future, an ideal vehicle for contribuir mejor a la comprensión y el abordaje de las integrating HP and SDH is the concept and emerging inequidades en salud. No obstante, normalmente se han methods of “Health in All Policies” (5) with its focus aplicado como dos cuestiones separadas. En este artículo se on engaging stakeholders at individual, community, presentan los elementos clave, los principios, las acciones and policy levels to improve health and health equity. y las posibles sinergias de estos marcos complementarios Integrating HP and SDH also affords the opportunity para abordar la equidad en salud. El valor añadido de la to underscore the importance of better grounding integración de estos dos enfoques se ilustra mediante tres HiAP in human rights approaches (45). By integrat- ejemplos extraídos de las experiencias de los autores en la ing the strengths of the HP and SDH approaches, we Región de las Américas: a nivel de la comunidad, mediante can further the evidence base and the social justice una coalición comunitaria dirigida a reducir las dispari- underpinnings of ensuring conditions for health and dades en relación con las enfermedades crónicas entre las minorías de un centro urbano de los Estados Unidos; a health equity. escala nacional, mediante las intervenciones de promoción de entornos saludables en Canadá; y a nivel regional, me- Conflicts of interest. None. diante la cooperación en salud basada en los valores de la justicia social en América Latina. También se analizan las sinopsis dificultades que entraña integrar los enfoques de la promo- ción de la salud y de los determinantes sociales de la salud Sinergia para la equidad en salud: integración en la Región de las Américas. de los enfoques de la promoción de la salud y de los determinantes sociales de la salud Palabras clave: promoción de la salud; desigual- dentro y fuera de la Región de las Américas dades en la salud; directrices para la planificación en salud; vulnerabilidad en salud; política social; salud Los enfoques de la promoción de la salud y de los deter- urbana; Américas. minantes sociales de la salud, cuando se integran, pueden

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