Chapter 9. Social determinants of health: from monitoring to multisectoral action

Overview

Although health inequalities can be driven by health system performance deficiencies, they are also impacted by broader conditions outside the medical and health sector that influence health outcomes. Social determinants of health (SDH) refer to the conditions in which people are born, grow, work, live, and age, and people’s access to power, money and resources (1). SDH encompass factors important for health in daily life such as income security and social protection, education, employment and job insecurity, good working conditions, food security, good-quality physical environment (including housing and basic amenities), early childhood development, social inclusion and nondiscrimination, security (the absence of violence), and access to affordable health services of good quality (1).

SDH have a powerful influence on health and are major drivers of health inequalities. SDH frameworks can help to distil evidence on the wide range of factors important for sustaining healthy living and working conditions and on the core causal mechanisms through which health inequalities emerge. Moreover, understanding how population groups variably experience SDH, and the mechanisms behind them, is an essential part of responses to improve health and reduce health inequity.

Interventions and policies addressing SDH, such as early education programmes and social protection, can have positive effects on health and the reduction of health inequalities. Due to the cross-cutting nature of SDH, taking action to address them is strengthened through collaborations across health and non-health sectors. Approaches such as Health in All Policies (HiAP) – “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” (2) – are crucial to embed SDH and health interests in policies across sectors.

As the area of SDH is vast and other guides exist describing the context for action and the monitoring of SDH for advancing health equity (3, 4), the objectives of this chapter are to recognize the importance of SDH in understanding and addressing health inequalities, to initiate discussion about actions on SDH, and to propose strategies for building and sustaining multisectoral partnerships. Following an overview of the political commitments to addressing SDH on the global health stage, this chapter discusses the application of inequality monitoring approaches to assess inequalities in SDH. It provides examples of how SDH data have been used to address health inequalities as part of multisectoral collaborations and an integrated HiAP approach. This chapter refers to a selection of resources for further exploration of these topics.

Political commitments

Over the past half-century, although many countries have witnessed remarkable health gains, unacceptable gaps still persist in health within and across countries. Decades of research show the powerful influence of SDH on population health and health inequities, as recorded in the final 2008 report of the WHO Commission on the Social Determinants of Health. This report called on WHO and all governments to lead global action on SDH in accordance with three overarching recommendations: improve daily living conditions; tackle the inequitable distribution of power, money and resources; and measure and understand the problem and assess the impact of action (5). The third of these recommendations set a global mandate for health monitoring in service of addressing health equity and the SDH by calling for a global health equity surveillance framework that included monitoring of health equity and social determinants (Box 9.1).

BOX 9.1. WHO Commission on the Social Determinants of Health recommendations regarding monitoring

The Commission recommended three specific actions on monitoring:

• Ensure routine monitoring systems for health equity and social determinants are in place locally, nationally and internationally.

• Invest in generating and sharing new evidence on how social determinants influence population health and health equity, and on the effectiveness of measures to reduce health inequities through action on social determinants.

• Provide information about social determinants to policy actors, stakeholders and practitioners, and invest in raising public awareness (5).

Following this recognition of the importance of addressing SDH, intensified efforts were made to advance political will for multisectoral approaches and governance under the banner of HiAP and technical work on monitoring SDH. A number of high-level commitments to address SDH were made, including the 2010 Adelaide Statement on Health in All Policies (6) and the 2011 Rio Political Declaration on the Social Determinants of Health (7). The Declaration of Oslo on Social Determinants of Health put SDH on the agenda of the World Medical Association and its national representative groups (8). Over the period of 2013–2017, parallel efforts on HiAP led to WHO regional position statements (9), the new definition of HiAP and the Helsinki Statement on HiAP (2), and technical resources describing how to take action through a global training programme on HiAP (10).

Through the Rio Political Declaration, countries expressed a commitment to “achieve social and health equity through action on the social determinants of health and well-being by a comprehensive intersectoral approach”, including a pledge to establish and strengthen monitoring systems that provide disaggregated data for assessing health inequalities (7).

WHO Member States have reinvigorated the call for a unified political commitment to address SDH. In 2021, at the 74th WHO World Health Assembly, Member States requested WHO to develop an operational framework for the measurement and assessment of SDH and health inequities, how they are addressed from a cross-sectoral perspective, and their impact on health outcomes (11).

Monitoring social determinants of health

Monitoring SDH involves “systematically collecting, analysing and reporting data on SDH and action indicators across multiple sectors” (3). When performed through an equity lens, evidence about SDH contributes to a broader understanding of population health and provides insight into the factors and actions that drive health inequalities, which can be used to inform evidence-based policy-making.

Monitoring SDH is critical to achieve health equity, for a number of reasons (3). Assessments of SDH data can reveal sources of injustices in SDH and related policies and interventions. Monitoring SDH and related actions can help to show what conditions and actions promote or detract from health and drive or reduce health gaps. It can lend understanding to whether interventions, policies and investments are addressing and improving SDH. Integrating SDH in health inequality monitoring provides a way for countries to measure and track progress towards health equity over time. In this way, monitoring SDH can strengthen accountability and transparency. Box 9.2 lists further reading on the evidence about SDH monitoring.

BOX 9.2. Further reading on evidence about SDH monitoring

Biermann O, Mwoka M, Ettman CK, Abdalla SM, Shawky S, Ambuko J, et al. Data, social determinants, and better decision-making for health: the 3-D commission. J Urban Health. 2021;98(Suppl. 1):4–14. doi:10.1007/s11524-021-00556-9.

De Paz C, Valentine NB, Hosseinpoor AR, Koller TS, Gerecke M. Intersectoral factors influencing equity-oriented progress towards universal health coverage: results from a scoping review of literature. Geneva: World Health Organization; 2017 (https://iris.who.int/handle/10665/255607, accessed 4 September 2024).

Donkin A, Goldblatt P, Allen J, Nathanson V, Marmot M. Global action on the social determinants of health. BMJ Global Health. 2018;3(Suppl. 1):e000603. doi:10.1136/bmjgh-2017-000603corr1.

Pega F, Valentine NB, Rasanathan K, Hosseinpoor AR, Torgersen TP, Ramanathan V, et al. The need to monitor actions on the social determinants of health. Bull World Health Organ. 2017;95(11):784–7. doi:10.2471/BLT.16.184622.

Valentine NB, Koller TS, Hosseinpoor AR. Monitoring health determinants with an equity focus: a key role in addressing social determinants, universal health coverage, and advancing the 2030 sustainable development agenda. Glob Health Action. 2016;9:34247. doi:10.3402/gha.v9.34247.

Working Group for Monitoring Action on the Social Determinants of Health. Towards a global monitoring system for implementing the Rio Political Declaration on Social Determinants of Health: developing a core set of indicators for government action on the social determinants of health to improve health equity. Int J Equity Health. 2018;17(1):136. doi:10.1186/s12939-018-0836-7.

Following the general approach described in Chapter 2, the steps for monitoring health inequalities can be applied to quantify differences in SDH indicators between subgroups constructed on the basis of economic status, education level, place of residence, sex, subnational region or other dimensions of inequality (see Annex 1 for more on monitoring inequalities in SDH). Familiarity with SDH within a population – including how SDH are differentially experienced by population subgroups – can inform the selection of relevant health indicators and dimensions of inequalities for monitoring. SDH evidence can be presented alongside the results of other health inequality analyses to set the scene for reporting, and when developing key messages and recommendations.

Monitoring SDH with an equity focus is concerned with indicators describing actions to improve the distribution of power, resources and environments for populations, and indicators that describe the conditions of daily life.

As an extension of health inequality monitoring, ecological analyses can be conducted to assess correlations between SDH and health indicators. These techniques, covered in Chapter 25, can reveal high-level associations between SDH variables and health indicators, measured at the population level. Assessing the relationships between SDH and health indicators can help to better understand factors explaining population health. Although such assessments of association cannot confirm causation, the results of these analyses can serve as a starting point for conducting further studies.

Systems for monitoring SDH have been in place at the global, regional, national and local levels from the 1990s onwards, but they have tended to have limited impact, particularly at the national level. Few countries systematically monitor SDH and actions to improve health equity or use the data generated to develop policies aimed at closing health gaps. Although data pertaining to many of the indicators for SDH conditions and policies have been collected, it is rare that they are explicitly linked to health information systems or accountability systems for health equity.

In 2024, WHO published the Operational framework for monitoring social determinants of health equity (Box 9.3). The Framework provides countries with critical guidance on monitoring SDH and health inequality and on actions to address them. The Framework addresses the use of monitoring systems to generate and support policy action across sectors to improve health equity (3).

BOX 9.3. WHO Operational framework for monitoring social determinants of health equity

The WHO Operational framework for monitoring social determinants of health equity helps to support data-driven decision-making for policy-makers and practitioners to improve the health of all populations. It serves as an important tool towards creating fairer societies and healthier lives (3).

The Framework consists of two main components. The first component is a globally applicable and harmonized menu of indicators for monitoring across six SDH domains: economic security and equality; education; physical environment; social and community context; health behaviours; and health care. For each domain, there are multiple subdomains representing more specific SDH and related actions. Within each subdomain, indicators are identified along with corresponding dimensions of inequality. For example, for the domain of economic security and equality, poverty is a subdomain and a corresponding indicator is the percentage of the population living below the national poverty level. The menu includes indicators for determinants and related actions such as policies and interventions.

The second component provides guidance on actions for monitoring SDH equity, incorporating relevant lessons learnt from countries. Building on existing WHO tools for health inequality monitoring, it addresses the process for technical monitoring of SDH and related actions at the national and subnational levels, the use of data to inform policy for health equity at the national and subnational levels, and the harmonization of monitoring at the regional and global levels.

Alongside the Framework, the WHO World report on social determinants of health equity (12) and guidance on multisectoral collaboration in Working together for equity and healthier populations (13) present a way forward for countries to renew action and to build multisectoral policy collaboration mechanisms and capacities.

Acting on the social determinants of health

SDH converge and accumulate over the life course in complex ways, reflecting the unequal distribution of power and resources among population subgroups. The development of explicit action plans and strategies to address SDH are complex and multisectoral in nature – and their implementation has been slow and uneven across countries, despite growing political attention and mounting evidence. There are a number of reasons for this. The expansive nature of SDH as a concept and the high level of complexity involved in understanding and addressing SDH often make it challenging for governments to take coordinated action. There are challenges in terms of high-level political will and accountability because SDH cover different, often siloed government ministries and interest groups in society at large (14). Because many of the health effects related to SDH accumulate over the life course, the impact of remedial actions may not be evident in the short term – which may disincentivize or deprioritize such actions.

Encouragingly, however, many countries are increasingly taking explicit actions to act on SDH, including implementing HiAP approaches. At the global level, country-level actions are supported by the Alliance for Health Policy and Systems Research – a partnership hosted by WHO whose mandate includes supporting the generation and use of research to address SDH and reduce health inequities (15). In response to the heightened demand for evidence on SDH and their relationship to health, the health and social protection academic community has developed research initiatives to explore policies addressing multiple SDH across domains related to food, climate change and social protection (Box 9.4).

BOX 9.4: Social protection measures

Financial security is highly impactful on health outcomes, care-seeking, and the consequences of illness in people’s lives. One area of public policy that addresses financial security across the life course is social protection measures. These measures refer to nationally defined systems of policies and programmes that provide equitable access to all people and protect them throughout their lives against poverty and risks to their livelihoods and well-being (16).

Social protection measures exist in different forms across many countries. These measures can include cash or in-kind benefits (e.g. related to parental leave, disability, work injury benefits or pensions), contributory or noncontributory schemes (e.g. insurance), and programmes to enhance human capital, productive assets or access to jobs (e.g. skills development programmes) (17). The United Nations Collaboration on Social Protection recognizes the importance of social protection policies for achieving the Sustainable Development Goals, including those impacting multiple SDH (18, 19).

Universal social protection measures can prevent and reduce poverty, enhance social inclusion, and protect the dignity of people facing discrimination or disadvantage. While contributing to economic growth, these measures can also foster development by enhancing nutrition access, increasing participation in school and stemming exploitative (child) labour practices. Further, they can offer recourse to people experiencing the negative effects of pandemics, natural disasters and economic constraint.

The impacts of social protection measures can be tracked through health inequality monitoring. Inequality monitoring can yield important insights into where social protection efforts are having a beneficial impact and where targeting may be required. This requires a structured process of identifying relevant indicators and dimensions of inequality and monitoring them over time (20). For example, one important indicator of social protection included in the United Nations 2030 Agenda for Sustainable Development and the WHO Fourteenth General Programme of Work for 2025–2028 measures the proportion of population covered by at least one social protection benefit (21, 22).

Examples of specific effort to address SDH more comprehensively can be found in several countries. In China, the Health China 2030 plan was developed by more than 20 governmental departments, which put forth a vision for an expanded health industry that would become a pillar of the national economy. Aiming to achieve health equity by 2030, a key component of the plan is the promotion of a healthy lifestyle and physical fitness, including a focus on disease prevention (23).

In Zambia, the Ministry of Health has a department dedicated to health promotion and SDH. It is mandated to fulfil functions such as collaborating with stakeholders on addressing environmental and social hazards to health; developing and implementing workplace wellness policies; and developing and implementing strategies to transform social structures for health and socioeconomic well-being (24).

In Thailand, actions on SDH – under the umbrella of an HiAP approach – have included the creation of enabling policy environments to promote healthy diets and nutrition, realized, for example, through the implementation of school feeding policies and programmes (25).

WHO efforts to harmonize guidance for action, networking and amplifying actions to address SDH with a specific focus on advancing health equity across multiple countries are under way (Box 9.5).

BOX 9.5. WHO Special Initiative for Action on Social Determinants of Health for Advancing Health Equity

Launched in 2021, the WHO Special initiative for Action on Social Determinants of Health for Advancing Health Equity has the goal of demonstrating the “effectiveness of strategies, policies, models and practices through improving the social determinants of health for at least 20 million disadvantaged people in at least 12 countries by 2028” (26). The eight-year initiative comprises a broad range of collaborators from WHO, development agencies, academic institutions and national governments (27).

With an initial focus on nine pathfinder countries and territories across three WHO regions (Chile, Colombia, Costa Rica, El Salvador and Peru in the Region of the Americas; Morocco and the occupied Palestinian territory, including east Jerusalem, in the Eastern Mediterranean Region; and the Lao People’s Democratic Republic and the Philippines in the Western Pacific Region) (28), the initiative is rooted in a theory of change development process. Barrier mapping resulted in identification of gaps in understanding, integration, under-prioritization of structural determinants, underrepresentation of communities, and few forums and incentives for policy shifts. The initiative set about expanding knowledge and narratives for scale-up of existing actions (which in some cases have navigated or directly tackled barriers). Emphasis in pathfinder countries will be on addressing structural determinants. Across countries, emphasis is proposed on networking across academic, worker, decision-maker and community change agents. Initial themes of the initiative are employment precarity, income and food security, housing and social services.

Partnerships: the role of multisectoral collaboration

Inequalities in health and SDH are complex challenges for governments. Deliberately addressing these inequalities requires coordinated action across sectors to ensure policies and institutions positively reinforce each other (13). Multisectoral action – a term used interchangeably with the concept of intersectoral action – is the involvement of several sectors in developing and implementing public policies intended to improve health, equity, well-being and other policy outcomes (13). Multisectoral actions require some form of collaboration across sectors such as agriculture, education, environment, health, social welfare, and trade and industry. Indeed, engagement with multisectoral committees or secretariats is integral to the advancement of multisectoral action Table 9.1. Such structures provide opportunities for SDH monitoring systems and data to be linked more strongly to actions.

TABLE 9.1. Multisectoral governance structures and mechanisms

Level of government	Cabinet committees and secretariats
Parliament	Parliamentary committees
Public sector or civil service	Interdepartmental committees and units Mega-ministries and mergers Cross-sector working and technical groups
Management of funding arrangements	Joint budgeting Delegated financing
Engagement with nongovernmental entities	Communities and civil society Nongovernmental organizations Private sector

Source: adapted from the WHO Health in All Policies: training manual (10).

Working across multiple sectors towards a shared interest, collaborative actions are imperative to help reduce health inequities and achieve health goals and targets. This may be orchestrated through comprehensive HiAP approaches, whereby health actors have a proactive role in engaging with non-health sectors to influence policies, while seeking co-benefits for other public policy goals such as social protection, to advance population health and health equity.

Health in All Policies approaches

The foundations of the HiAP approach date back to the 1978 Alma-Ata Declaration and the 1986 Ottawa Charter for Health Promotion, although the approach was first articulated as a global-level strategy or approach for action on health determinants as part of the 2014 Helsinki Statement on Health in All Policies (2). HiAP approaches are defined by the following unique features: emphasis on formal governance structures and mechanisms poised to address emerging problems, even where information may be incomplete; explicit partnerships between health and other sectors; emphasis on co-benefits for health and development, and attention to conflicts of interest; investment in relationships of trust, with the expectation of a longer time horizon for impact; and focus on upstream social determinants that relate to inequities in power, money and resources (13).

HiAP approaches are relevant to the advancement of health equity when they adopt an equity focus, ensuring actions are oriented towards the reduction of inequalities alongside population-level improvements.

A new model of HiAP, which emphasizes the importance of collaboration (“seeking synergies”), is premised on four pillars:

• Pillar 1: governance and accountability, establishing the mandate and legitimacy for HiAP actions and collaborative mechanisms for cross-government efforts.

• Pillar 2: leadership at all levels, advocating for HiAP and other collaborative approaches, promoting a culture of collaboration and establishing a network of champions across sectors.

• Pillar 3: ways of working and work methods, using a co-production or co-design approach and building relationships of trust.

• Pillar 4: resources, financing and capabilities, ensuring adequate budgetary allocations, role clarity, and other capabilities necessary to address upstream determinants (13).

Box 9.6 demonstrates how these four pillars are evident in operations of the California HiAP Task Force in the United States of America, which convenes over 25 state government departments and agencies to advance health equity.

BOX 9.6. Applying the principles of Health in All Policies in California

The following demonstrate how the four pillars of the HiAP model are featured in the multisectoral and multistakeholder mechanisms and operations of the California HiAP Task Force of the California Strategic Growth Council (29):

• Governance and accountability: the Task Force was established in 2010 through a Governor’s Executive Order (S-04-10), affirmed by the legislature in 2012, and subsequently affirmed through a budget act in 2019 that formally committed Government-funded staff positions for continued work. Funding requirements and public accountability mechanisms ensure priorities are driven by public input and ensure a whole-of-government approach, which is novel in the United States. Reporting through a cabinet-level council is critical for ensuring leadership support and public transparency.

• Leadership at all levels: a blend of Government and nongovernment leadership has been critical for success. Within the Government, executive leaders lend political support to health and racial equity issues. Subject matter experts bring experience and solutions-oriented approaches as members of the Task Force. Outside the Government, advocacy groups, community members and nongovernmental organizations shape priorities, guide solutions, demand transparency and hold the Government accountable.

• Ways of working and work methods: the Task Force is built on trust, collaboration, co-benefits and co-design. This has been particularly important due to the lack of legislated mandates for participating organizations and limited funding for this work. Every participating entity must benefit to remain involved. This way of working includes involvement of civil society. As the Task Force affirms its focus on racial equity, it is taking steps to further centre the voices of affected communities.

• Resources, financing and capabilities: the facilitation staff of the HiAP Task Force come from three different organizations – the cabinet-level Strategic Growth Council, the non-profit-making Public Health Institute, and the California Department of Public Health. Each of these organizations has a different role in the partnership based on strengths and positionality. The Strategic Growth Council leverages the connection with the Governor’s Office for executive-level support. The Public Health Institute connects with outside advocate groups and community-based organizations for grassroots support. The Public Health Institute and the California Department of Public Health both bring public health expertise. The California Department of Public Health connects the Task Force with local health jurisdictions. Building the case for Government-funded HiAP positions has been essential for the staffing of this initiative and a key programmatic outcome of normalizing the concept of a whole-of-government approach to health and racial equity.

Whole-of-government and whole-of-society approaches are part of implementing HiAP (13). A whole-of-government approach describes collaborations across various ministries or agencies at the national, provincial or local levels (Pillar 2). Whole-of-society approaches cast this net broader, focusing on the inclusion of stakeholders from outside government. Such stakeholders may include academia and universities, communities, civil society, nongovernmental organizations, and the private sector (which includes a diverse range of economic or commercial enterprises that involve processes or products that may promote or harm health). Once established, such collaborations have the potential to complement and augment the impact and sustainability of siloed hierarchical approaches to promoting health, and indeed, to complement health-care systems.

There are promising examples of HiAP at local community levels (30). In comparison with national and subnational governments, authorities working within more decentralized contexts operate in closer proximity to the community and are therefore better positioned to engage with their needs and respond to challenges and opportunities. Box 9.7 lists further reading with more examples of case studies and research on HiAP.

BOX 9.7. Further reading on HiAP

Global status report on Health in All Policies. Adelaide: Government of South Australia and Global Network for Health in All Policies; 2019 (https://actionsdg.ctb.ku.edu/wp-content/uploads/2019/10/HiAP-Global-Status-Report-final-single-pages.pdf, accessed 18 September 2024).

Health in All Policies: experiences from local health departments. Washington, DC: National Association of County and City Health Officials; 2017 (https://www.naccho.org/uploads/downloadable-resources/NACCHO-HiAP-Report_Experiences-from-Local-Health-Departments-Feb-2017.pdf, accessed 18 September 2024).

Scheele CE, Little I, Diderichsen F. Governing health equity in Scandinavian municipalities: the inter-sectorial challenge. Scand J Public Health. 2018;46(1):57–67. doi:10.1177/1403494816685538.

Monitoring inequalities in SDH is critical in both shaping and evaluating the impact of HiAP. Determining which sectors should be involved in such an initiative could be identified on the basis of analysis of the dimensions of inequality associated with health outcomes, and of the correlation and further in-depth analysis of the links between population health and SDH conditions. For example, health inequalities related to economic status are often identified, which may prompt engagement with economic institutions, structures and policies to align commercial interests in support of population-level well-being and social prosperity (31). Tracking SDH indicators related to economic conditions and policies for income security provides further understanding of the current situation. Assessment of trends in health inequality and trends in SDH over time can provide an indication of how inequalities may have changed alongside the rollout of HiAP initiatives.

References

1. Social determinants of health. Geneva: World Health Organization (https://www.who.int/health-topics/social-determinants-of-health, accessed 20 June 2024).

2. Health in All Policies: Helsinki statement – framework for country action. Geneva: World Health Organization; 2014 (https://iris.who.int/handle/10665/112636, accessed 4 September 2024).

3. Operational framework for monitoring social determinants of health equity. Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/375732, accessed 23 September 2024).

4. Integrating the social determinants of health into health workforce education and training. Geneva: World Health Organization; 2023 (https://iris.who.int/handle/10665/373710, accessed 4 September 2024).

5. Commission on Social Determinants of Health. Closing the gap in a generation – health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008 (https://iris.who.int/handle/10665/43943, accessed 4 September 2024).

6. Adelaide statement on Health in All Policies: moving towards a shared governance for health and well-being. Geneva: World Health Organization and Government of South Australia; 2010 (https://iris.who.int/handle/10665/44365, accessed 4 September 2024).

7. Rio Political Declaration on the Social Determinants of Health. Rio de Janeiro: World Health Organization; 2011 (https://www.who.int/publications/m/item/rio-political-declaration-on-social-determinants-of-health, accessed 8 July 2024).

8. WMA Declaration of Oslo on Social Determinants of Health. Moscow: World Medical Association; 2015 (https://www.wma.net/policies-post/wma-declaration-of-oslo-on-social-determinants-of-health/, accessed 4 September 2024).

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10. Health in All Policies: training manual. Geneva: World Health Organization; 2015 (https://iris.who.int/handle/10665/151788, accessed 4 September 2024).

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23. Donkin A, Goldblatt P, Allen J, Nathanson V, Marmot M. Global action on the social determinants of health. BMJ Glob Health. 2018;3(Suppl. 1):e000603. doi:10.1136/bmjgh-2017-000603.

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27. Solar O, Valentine N, Castedo A, Brandt GS, Sathyandran J, Ahmed Z, et al. Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative. Int J Equity Health. 2023;21(3):193. doi:10.1186/s12939-022-01798-y.

28. Multicountry initiative: work in WHO regions. Geneva: World Health Organization (https://www.who.int/initiatives/action-on-the-social-determinants-of-health-for-advancing-equity/about/work-in-who-regions, accessed 23 September 2024).

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31. Occhipinti JA, Skinner A, Doraiswamy PM, Saxena S, Eyre HA, Hynes W, et al. The influence of economic policies on social environments and mental health. Bull World Health Organ. 2024;102:323–329. doi:10.2471/BLT.23.290286.