political factors essay

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Understanding How Politics Can Affect Your Business

• 19 Jul 2022

Politics can enormously impact business. For example, regional laws and regulations can determine how a company operates or whether it benefits from international expansion. For this reason, aspiring entrepreneurs, business leaders, and strategists in heavily regulated industries should familiarize themselves with politics’ effects on business.

Here's an overview of the role politics plays in business—domestically and internationally—and why it’s important to understand it.

Access your free e-book today.

Government's Role in Business

To understand government’s role in business, it's important to recognize its place in a country. In the online course Global Business , Harvard Business School Professor Forest Reinhardt explains that government has four basic functions:

• Protecting citizens from external harm
• Protecting citizens from internal threats
• Protecting property rights
• Creating means of resolving disputes

How governments fulfill these responsibilities significantly impacts businesses. For instance, to protect citizens’ well-being and guarantee a living wage, a government may impose a base pay requirement. The United States is one example, which enforces a federal minimum wage of $7.25 per hour .

Protecting citizens’ property rights also has a major impact on businesses. Those hoping to create organizations must be assured that they own the rights to their products. For this reason, governments establish copyright and trademark laws to ensure companies maintain ownership of their goods or brands.

International Factors

Several international political factors influence business when a company expands globally . The same is true when international companies become competitors by expanding into domestic territories.

A country's political nuances is one of the primary challenges of international business. Political leaders often make decisions that impact labor laws, education, transportation, and taxes, which, in turn, influence business. Navigating multiple countries’ political challenges isn't easy, so before expanding your business, it's critical to ensure it’s prepared for globalization .

Related: 6 Pros and Cons of Globalization in Business to Consider

Government Value Creation

Value creation in economics refers to the process of creating goods and services that are worth more than the resources used to produce them. Governments can create value in the same way as businesses by purchasing resources—like labor and raw materials—and using them to produce goods or services of higher value.

Compared to businesses, governments have greater power. For example, governments can compel individuals and businesses to pay taxes regardless of whether doing so will create value.

Governments often attempt to directly create value by producing public goods , which have two identifying factors:

• Non-rivalrous: An individual's consumption of goods doesn't prevent anyone else from accessing them.
• Non-excludable: Nobody is prevented from using the good.

Since public goods are accessible and benefit everyone, businesses don't often produce them because they don’t generate profit.

Public goods benefit businesses because they allow other entities to create value by using them. For example, a government provides education to the public, which produces skilled individuals businesses can hire.

Challenges of Government Politics

While politics can benefit businesses by creating value, it can also interfere with value creation. Whether through corruption, subsidization of domestic companies, or competitor globalization, several challenges can arise that threaten a company's well-being.

Domestic Challenges

One of the primary challenges organizations encounter is corruption. The ability to influence businesses—regardless of whether doing so creates value—can allow officials to take advantage of their power .

There are three primary forms of corruption in government:

• Extortion: Public officials using their power to obtain wealth through threats or force
• Theft: Public officials appropriating government assets for personal gain
• Capture: Firms paying government officials to influence political decision-making for profit

The primary form of corruption that influences businesses is capture. There are many instances where corrupt companies influence political decisions for their benefit, giving them a clear competitive advantage. While this kind of corruption is illegal in many countries, it's an expected part of business in others.

Even if organizations operate outside of such countries, corruption can play a large role in their decisions. For example, in mergers or acquisitions , it's important to examine a company's history for signs of corruption. If it’s found that a business’s success couldn't have been achieved without corruption, it’s a sign for the acquiring company to steer clear.

Investment decisions are also impacted by corruption. It's important to practice sustainable investing to ensure that any businesses you invest in aren't corrupt. While not always apparent, it's crucial to thoroughly research a company before investing to ensure it aligns with your moral standards and has strict anti-corruption policies in place.

International Challenges

An additional challenge pertaining to international business arises when international companies enter domestic markets. Consumers who purchase from your business could turn to international competitors. This can be difficult because your competition may provide similar products for lower costs.

One example Reinhardt presents in Global Business is a country subsidizing domestic companies. Additional funding from the government allows companies to produce more at a lower price for consumers, enabling them to expand to neighboring countries with a competitive advantage over domestic companies.

Related: 5 International Business Examples to Learn From

Another challenge of conducting international business is encountering situations where investments are withdrawn from a country. This can occur when governments take more power than they're entitled to. In these situations, such countries could become highly dangerous to conduct business in.

There may be times, however, when a withdrawal is necessary. Some of the primary reasons include:

• Corruption: Since capture is a prevalent form of corruption in many countries, companies need to recognize it when expanding.
• Financial crises: The great recession in Russia between 2008–2009 caused many companies to withdraw as the country prioritized domestic companies’ well-being over that of international ones.

The Importance of Understanding Global Politics

Understanding global politics is critical to your business's success, regardless of whether you plan to expand internationally . It's always possible an opportunity to globalize your business will arise.

Knowledge of global politics is also important because of international competition from foreign companies. Yet, global politics’ challenges can produce multiple opportunities. An effective business strategy takes both globalization and domestic factors into account.

If you're interested in learning more about how globalization and political activity impact your business, consider taking an online course, such as Global Business . Doing so can prepare you for the reality of globalization and the ramifications of political decisions on your business.

Are you interested in expanding your business internationally? Consider enrolling in Global Business —one of our online courses related to business in society —to learn more about the broader political landscape your organization operates in. Not sure which course is the right fit? Download our free course flowchart to determine which best aligns with your goals.

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How to Write the Political and Global Issues College Essay

Essays are one of the best parts of the college application process. With your grades in, your test scores decided, and your extracurriculars developed over your years in high school, your essays are the last piece of your college application that you have immediate control over. With them, you get to add a voice to your other stats, a “face” to the name, so to speak. They’re an opportunity to reveal what’s important to you and what sets you apart from other applicants and tell the admissions committee why you’d be an excellent addition to their incoming student class.

Throughout your college applications process, there are many different types of essays you’ll be asked to write. Some of the most popular essay questions you’ll see might include writing about an extracurricular, why you want to matriculate at a school, and what you want to study.

Increasingly, you might also see a supplemental college essay asking you to discuss a political or global issue that you’re passionate about. Asking this type of question helps colleges understand what you care about outside of your personal life and how you will be an active global citizen.

Some examples from the 2019-2020 cycle include:

Georgetown University’s Walsh School of Foreign Service : Briefly discuss a current global issue, indicating why you consider it important and what you suggest should be done to deal with it.

Yeshiva University Honors Programs : What is one issue about which you are passionate?

Pitzer College : Pitzer College is known for our students’ intellectual and creative activism. If you could work on a cause that is meaningful to you through a project, artistic, academic, or otherwise, what would you do?

Your GPA and SAT don’t tell the full admissions story

Our chancing engine factors in extracurricular activities, demographics, and other holistic details. We’ll let you know what your chances are at your dream schools — and how to improve your chances!

Our chancing engine factors in extracurricular activities, demographic, and other holistic details.

Our chancing engine factors in extracurricular activities, demographic, and other holistic details. We’ll let you know what your chances are at your dream schools — and how to improve your chances!

Tips for Writing the Political and Global Issues College Essay

Pick an issue close to your life.

When you first see a political and global issues prompt, your gut reaction might be to go with a big-picture topic that’s all over the news, like poverty or racism. The problem with these topics is that you usually have a page or less to talk about the issue and why it matters to you. Students also might not have a direct personal connection to such a broad topic. The goal of this essay is to reveal your critical thinking skills, but the higher-level goal of every college essay is to learn more about who you are.

Rather than go with a broad issue that you’re not personally connected to, see if there’s just one facet of it that you  can  contend with. This is especially important if the prompt simply asks for “an issue,” and not necessarily a “global issue.” While some essay prompts will specifically ask that you address a  global  issue (like Georgetown’s School of Foreign Service), there are still ways to approach it from a more focused perspective.

For example, if you were to talk about world hunger, you could start with the hunger you see in your community, which is a food desert. For your solution, you can discuss your plan to build a community garden, so the town is able to access fresh produce. Food deserts, of course, aren’t the only reason world hunger exists; so, you should also explore some other reasons, and other solutions. Maybe there is a better way to prevent and recuperate produce currently being wasted, for instance. If the prompt doesn’t specifically ask for a global issue, however, you could simply focus on food deserts.

For another example, maybe you want to talk about climate change. A more personal and focused approach would deal with happenings in your community, or a community you’ve had contact with. For instance, perhaps your local river was polluted because of textile industry waste; in this case, it would be fitting to address fast fashion specifically (which is still a global issue).

Remember your audience

As you’re approaching this essay, take care to understand the political ramifications of what you’re suggesting and how the school you’re addressing might react to it. Make sure you understand the school’s political viewpoints, and keep in mind that schools are hoping to see how you might fit on their campus based on your response.

So, if you’re applying to a school known for being progressive, like Oberlin or Amherst, you might not want to write an essay arguing that religious freedom is under threat in America. Or, if you’re applying to Liberty University, you should probably avoid writing an essay with a strong pro-LGBTQ stance. You don’t have to take the opposite position, but try picking a different issue that won’t raise the same concerns.

If you have no political alignment, choose economics

If you find yourself applying to a school with which you share no political viewpoints, you might want to consider if the school would even be a good fit for you. Why do you really want to go there? Are those reasons worth it? If you think so, consider writing about an economic issue, which tend to be less contentious than social issues.

For instance, you could write about the impact of monopolies because your parents own an independent bookstore that has been affected by Amazon. Or you could discuss tax breaks for companies that keep or move their production domestically, after seeing how your town changed when factories were moved abroad. Maybe tax filing is a cause you’re really passionate about, and you think the government should institute a free electronic system for all. No matter what you write about here, the key is to keep it close to home however you can.

Pick the best possible framing

When you’re writing an essay that doesn’t fully align with the political views of the school you’re applying to, you’ll want to minimize the gap between your viewpoint and that of the school. While they still might disagree with your views, this will give your essay (and therefore you) the best possible chance. Let’s say you’re applying to a school with progressive economic views, while you firmly believe in free markets. Consider these two essay options:

Option 1:  You believe in free markets because they have pulled billions out of terrible poverty in the developing world.

Option 2:  “Greed is good,” baby! Nothing wrong with the rich getting richer.

Even if you believe equally in the two reasons above personally, essay option 1 would be more likely to resonate with an admissions committee at a progressive school.

Let’s look at another, more subtle example:

Option 1:  Adding 500 police officers to the New York City public transit system to catch fare evaders allows officers to unfairly and systematically profile individuals based on their race.

Option 2:  The cost of hiring 500 additional police officers in the New York City public transit system is higher than the money that would be recouped by fare evasion.

While you might believe both of these things, a school that places a lower priority on race issues may respond better to the second option’s focus on the fallible economics of the issue.

Structuring the Essay

Depending on how long the essay prompt is, you’ll want to use your time and word count slightly differently. For shorter essays (under 250 words), focus on your personal connection rather than the issue itself. You don’t have much space and you need to make it count. For standard essays (250-500 words), you can spend about half the time on the issue and half the time on your personal connection. This should allow you to get more into the nuance. For longer essays, you can write more on the issue itself. But remember, no matter how long the essay is, they ultimately want to learn about you–don’t spend so much time on the issue that you don’t bring it back to yourself.

Want help with your college essays to improve your admissions chances? Sign up for your free CollegeVine account and get access to our essay guides and courses. You can also get your essay peer-reviewed and improve your own writing skills by reviewing other students’ essays.

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Political Factors of Vietnam’s Struggle for Independence Research Paper

• To find inspiration for your paper and overcome writer’s block
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Vietnam was initially a French colony before the Second World War. However, like many other nations under European colonial rule, Vietnam had an excellent opportunity to achieve sovereignty, thwart the French’s imperialism in the area, and resist the influence of external powers after the war. Although Vietnam declared its independence from France on September 2 nd , 1945, its transition into a social republic marked a historical era of conflict and bloodshed. Nevertheless, the citizens of Vietnam were determined to regain their freedom from oppressors, which encouraged them to fight for their course for nearly three decades. Even so, the struggle for independence in Vietnam was a result of several elements that made it necessary and possible to rally insurgents and resist colonization. Following these events, Ho Chi Minh declared the nation’s independence in front of thousands of people in a gathering held in the largest city. The political components that facilitated Vietnam’s development toward self-governance include France’s defeat by Germany, the Japanese takeover, the emergence of the Viet Minh, American Support, and the surrender of Japanese forces to Vietnam in 1945.

The French suffered a massive defeat by Germany in 1940, which thwarted all its colonial efforts in Indochina, thus providing Vietnam with the opportunity to fight for its independence. By this time, the French had been in Vietnam for more than six decades and considered the region one of their most precious possessions. The French justified their imperialism in Vietnam with claims that they were destined to improve the lives of people and civilize the area (Namba 519). However, they were focused on cheap labor, production, and profits. In addition, they imposed imperialistic governance structures such as colonial taxes and took advantage of the nation’s resources. According to Johnson, laborers in Indochina were exposed to pathetic living conditions for significantly low pay. While some worked in rice and rubber farms voluntarily, others were forced to serve in plantations at gunpoint (3). As a result, the French’s defeat by Germany in 1940 allowed Vietnam the chance to regain its sovereignty, fight for the freedom of its citizens, and expel the French from the territory. However, Japan also perceived this defeat as an opportunity to take over Vietnam and impose governance.

The Japanese invasion of Vietnam in 1940 after the fall of the French forces is another factor that encouraged the nation’s transition. The French’s surrender to Germany weakened their colonial rule in Vietnam, thus giving it limited options but to adhere to Japan’s demands to control the region (Whitmore 12). In addition, the ongoing China-Japan war encouraged the occupation of Vietnam since it enabled Japan to close off the southern border and prevent the supply of weapons (Guillemot 223). Nevertheless, the Japanese government had other motives because it intended to take advantage of resources and labor in Indochina to advance its industries and increase production. Even so, they allowed the French to govern some territories since they did not have enough personnel to oversee their initiatives. Regardless, some locals did not favor the Japanese despite their bid to be in people’s hearts (Guillemot 228). The Japanese government dealt with people in areas such as China ruthlessly, encouraging the Vietnamese to believe that they would cripple the nation in one way or another. Thus, local resistance against the Japanese grew with the help of Ho Chi Min and the Viet Minh.

The return of Ho Chi Minh to Vietnam and the formation of the Vietnam League of Independence (Viet Minh) had significant implications for the nation’s advancements toward declaring independence by facilitating organized resistance. Ho Chi Minh and other Vietnamese nationalists drew their political ideas from European nations as they argued against colonialism and imperialism (Tram and Dinh 1240). As a result, they formed secret societies, translated Western political texts, and compared their situations with other Asian countries including China, which encouraged them to forge nationalist links within Indochina and spearhead the formation of the military faction. The Viet Minh welcomed all individuals including communists and non-communists to strengthen its growth, allowing it to accommodate civil servants, young men, women, merchants, intellectuals, and peasants who grew to become a powerful force (Johnson 4). The group generally relied on guerrilla tactics and foreign assistance but their technique was effective enough to drive out the Japanese and French imperialists. Together, they battled the Japanese invaders and drove them out of most territories over time. Even so, the US had a hand in Vietnam’s success in declaring its independence because it supported its endeavors.

US involvement in Vietnam affairs and the assistance they offered the Viet Minh put the nation in a better position to subdue their adversaries because they had access to resources and military training. Although the US was not engaged in war with Japan in the 1940s, it worked to restrict the nation’s expansion in Asia. Similarly, the US wanted to protect its raw rubber imports, most of which came from Japan (Whitmore 16). As a result, the American government partnered with the Viet Minh and Go Chi Minh to drive out the Japanese in 1945. The US provided Viet Minh fighters with weapons and trained them in war tactics in exchange for information regarding the movements of Japanese troops and the size of their military (Tram and Dinh 1242). In addition, the deal required the Viet Minh to rescue American air fighters shot down over their territories, and constantly harass the Japanese to evict them from the region. The assistance Ho Cho Minh and the Viet Minh received from the US encouraged them to put in effort toward the struggle as they hoped for similar support in their independence declaration.

The Japanese takeover and its subsequent evacuation of the French colonial regime paved the way for Vietnam’s independence as it enabled the nation to regain its powers. The beginning of 1945 was a devastating period for Japan because they had surrendered to the Philippines and were retreating all over South Asia, losing their territories, and suffering heavy losses (Johnson 8). Although the Japanese government considered Vietnam its stronghold, its occupation force withdrew from the region’s capital and halted its support for the regime with claims that the French were assisting their adversaries. Subsequently, Vietnamese soldiers removed the French from power, disarmed, arrested, and locked up all French officers (Guillemot 232). The Viet Minh took this opportunity to strengthen its forces and recruit more officers since Japan was yet to surrender control of its territories. As a result, they were better positioned to defend their position but did not attack because Japan was already failing in its war initiatives with nations allied with Vietnam.

Japan’s surrender was the ultimate factor that allowed Vietnam to declare its independence and transition toward gaining total control of its country. Over the coming months, the Viet Minh consolidated its control of the North Western area and significantly grew in numbers. By the beginning of August, Vietnam’s resistance was strong and continuously drove out the Japanese from most regions (Whitmore 36). The Viet Minh seized most Japanese-controlled towns and villages and gradually increased their domination. Nevertheless, the Hiroshima and Nagasaki disaster after the US dropped atomic bombs on the two cities forced the Japanese into surrender as they mobilized to leave Vietnam. On the 2 nd of September 1945, Ho Chi Minh led Vietnamese citizens in declaring their sovereignty and independence from France (Namba 542). Their proclamation heavily borrowed from the US declaration of independence and ushered new a new era of standing against their adversaries.

Vietnam’s road to gaining absolute control over its nation featured long periods of conflict, bloodshed, and economic losses. By the time the nation gained its independence from France, millions of lives had been lost and many people were left homeless. Even so, the factors that led to Vietnam’s transition toward independence encouraged their unwearied fight to achieve their goals. Particularly, the French’s loss to Germany in 1940, the Viet Minh, support by the US, and the failure and subsequent surrender of the Japanese to Vietnam created room for the nation to materialize its ambitions. Although the country’s dream of independence took several years to achieve and resulted in adversities, their success provided an opportunity for reconstruction and positive advancement as they drove out all external forces from the area.

Works Cited

Guillemot, François. “Vietnamese Nationalist Revolutionaries and the Japanese Occupation: The Case of the Dai Viet Parties (1936–1946).” Imperial Japan and National Identities in Asia, 1895–1945 , edited by Robert Cribb, Narangoa Li, 1 st ed., Routledge, 2020, pp. 221-248.

Johnson, Nicholas. “Ho Chi Minh and the Vietnamese Struggle for Independence: A Historiographical and Instructional Capstone Project.” (2019). History – Master of Arts in Teaching . 7.

Namba, Chizuru. “The French Colonization and Japanese Occupation of Indochina during the Second World War: Encounters of the French, Japanese, and Vietnamese.” Cross-Currents: East Asian History and Culture Review vol. 8, no. 2, 2019, pp. 518-547.

Tram, Pham Ngoc, and Dinh Tran Ngoc Huy. “Educational, Political and Socio-Economic Development of Vietnam Based on Ho Chi Minh’s Ideology.” Ilkogretim Online vol. 20, no. 1, 2021, pp. 1238-1246.

Whitmore, John K. “Communism and History in Vietnam.” Vietnamese Communism in Comparative Perspective , edited by William S Turley, 1 st ed., Routledge, 2019, pp. 11-44.

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The political determinants of health: a global panacea for health inequities.

• Daniel E. Dawes , Daniel E. Dawes Satcher Health Leadership Institute, Morehouse School of Medicine
• Christian M. Amador Christian M. Amador Satcher Health Leadership Institute, Morehouse School of Medicine
•  and  Nelson J. Dunlap Nelson J. Dunlap Satcher Health Leadership Institute, Morehouse School of Medicine
• https://doi.org/10.1093/acrefore/9780190632366.013.466
• Published online: 19 October 2022

The political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health. Globally, recurring examples of the role that these political determinants—through government action or inaction, and policy—are playing in health outcomes and life expectancy, particularly in under-resourced communities, can be observed currently as well as historically. Most notably, the political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. They involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. Focusing on the political determinants of health homes in on the fundamental causes that give rise to, sustain, and exacerbate the social determinants of health that create and worsen the persistent and devastating health inequities that are observed, experienced, researched, and reported. By employing both a theoretical and practical lens to the amelioration of health inequities that continue to pervade communities across the globe, the article contextualizes many of the historic harms that have occurred throughout history, providing a unique perspective on the current state of affairs, and offering a tangible path forward toward a more equitable future. Furthermore, consideration of this new framework at all levels of government as it relates to improving health outcomes for any nation is imperative in order to eliminate existential threats for any and all populations.

• political determinants of health
• health equity
• structural racism
• social determinants of health

Introduction

Globally, progress has been made to reduce racial and ethnic health inequities; address unjustified discrimination in health care access, quality, and value; and expand the conversation about their root causes. Today, the social determinants of health are widely recognized as contributing—and even determining—as much, and often even more, to the health and well-being of individuals than medical care and genetics. Additionally, as greater attention is paid to the social determinants of health, the deleterious consequences of racism and racial bias simply cannot be—and increasingly are no longer being—ignored. However, for elimination of the health inequities that sit downstream to occur, addressing the upstream factors must take place first, with a focus on the political determinants of health that provide the momentum and currents that have created and sustained the social determinants of health, which in turn have fueled and resulted in the disproportionalities in health, life expectancy, and quality of life. Opportunistic in nature, these socioecological disproportionalities have created synergies with biological factors that were observed during the COVID-19 pandemic leading to worst-case scenarios for many low- and middle-income countries globally, syndemic situations with both communicable and noncommunicable diseases ( Yadav et al., 2020 ).

One such example lies within the country of India, which had battled a tuberculosis epidemic for years and found itself crippled when the COVID-19 pandemic struck. This disrupted efforts to contain and treat tuberculosis due to the need to shift resources to address the COVID-19 virus or arguably because it was unequipped to handle the two scenarios simultaneously. In a country that suffers no shortage of risk factors for tuberculosis including air pollution, smoking, inadequate treatment of infection, HIV, overcrowded living conditions, and an increased burden of diabetes that can lead to severe multi-organ tuberculosis infection, India also had to deal with suboptimal governmental policies creating a precarious situation for the country’s public health. Surveillance still relied on a dated paper-based system for recording and reporting. There was a lack of prior planning to ensure uninterrupted tuberculosis drug supply, and disruption in the transportation of patient samples, tuberculosis drugs, and lab supplies, which have collectively contributed to the worsening of tuberculosis in the country during the COVID-19 pandemic ( Bardhan et al., 2021 ). Like India, there are countless other stories to recite across the globe in which the COVID-19 pandemic has opportunistically disrupted a country’s essential public health services, incapacitating already disadvantaged groups even further.

The concept of political determinants of health is introduced to inform thinking on how the structural conditions in which people are born, live, and die are developed over time; how political determinants of health create the milieu—such as environmental conditions, housing security, transportation access, and food options—that determine all aspects of health and life; and how they are the fundamental creators, perpetuators, and drivers of health inequities. By then equipping the reader with an application of the political determinants of health, a simple snapshot of a complex and highly reticulated concept is presented. This article is not designed to be all encompassing but rather aims to highlight key considerations and concepts of a complex topic, while offering a new framework for readers to use as they consider the impact of politics and policies locally, nationally, and internationally over time on the health, well-being, and lives of their respective population groups.

Cultivating and Advancing Health Equity: Social Determinants of Health

A society cannot expect to create change and cultivate a more equitable one without first looking at the structures in which people are born or placed. How can a society mobilize and advocate with disadvantaged, marginalized, and under-resourced populations and their communities to fight for equitable health care and resources? To truly move the needle of health equity forward, it is paramount to first acknowledge and address the systemic barriers that exist and persist. The reality is that in every country of the world, that nation’s health is not an organic outcome. It is not a coincidence that certain groups of people experience higher premature death rates than others. It is not a fluke that some groups experience poverty for generations, blocked from attaining their health potential. The depths of the problem may go unseen up until the point of exploration, a search for and examination of their root causes and distribution. This includes the social determinants of health, which are defined by the World Health Organization (WHO) (2022a ) as follows:

The social determinants of health are the conditions in which people are born, grow, live, work and age, and also includes the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. ( WHO, 2022a )

By understanding these circumstances, the root causes of disparities in care for vulnerable populations as well as strategies to address them can begin to be identified. Characteristics such as race or ethnicity, religion, socioeconomic status (SES), female gender, age, mental health, disability, sexual orientation or gender identity, and geographic location, among others, have historically been linked to exclusion or discrimination and are known to influence health status ( Dawes, 2016 ). Over time, efforts to understand the epidemiology of health outcomes, conditions, contexts, and disparities have begun to provide important information needed to identify the populations that are disproportionately affected by systemic racism, health inequities, and social and environmental disparities.

Several existing publications highlight the role that structural and systemic racism play as a cause of all health and social disparities ( Benjamins et al., 2021 ; Smedley et al., 2003 ; Williams et al., 2019 ). The COVID-19 pandemic and the disproportionate and deleterious impact that it has and continues to have on minoritized and marginalized communities globally uncovered even further how deeply racism is embedded within the social determinants of health. The COVID-19 pandemic, arguably a syndemic, has impacted everyday life in most countries in many ways, but none more so than the prioritization of health care. In the United States, for example, African American, Native American, Latin(o/a/x), and Pacific Islander families experienced disparities in everything from fatalities due to the virus to educational inequalities for children as schools shifted to remote learning. From the pandemic, it was learned that people of color are at an increased risk for serious illness if they contract COVID-19, due to higher rates of underlying health conditions, as compared to Whites. People of color are more likely to be uninsured and to lack a usual source of care, which is an impediment to accessing COVID-19 testing and treatment services. People of color are more likely to work in the service industries such as hospitality and retail that may put them at risk for loss of income during a pandemic. People of color are more likely to live in housing situations, such as multigenerational families or low-income and public housing, that make it difficult to practice social distancing or self-isolate. People of color often work in jobs that are not amenable to virtual or remote work and depend on public transportation, putting them at higher risk for COVID-19 exposure. As a result of this environment of socioeconomic, political, and cultural adversity, the psychosocial stress inflicted upon people of color, specifically Blacks in America, has contributed to the troubling metaphor developed by Dr. Arline Geronimus known as the “weathering” hypothesis, which results in the acceleration of the overall biological and aging process for these individuals ( Forrester et al., 2019 ; Geronimus et al., 2006 ).

A unifying, yet irrefutable, fact is that health inequities, and the political determinants of health that propagate them, are a global phenomenon. Across developed and developing countries alike, recurring examples of the role that policy and legal decisions are playing in the downstream health outcomes of individuals, particularly in under-resourced communities, have been observed. Take, for example, President Jair Bolsonaro of Brazil. As president of a country with one of the highest COVID-19 mortality rates in the world, President Bolsonaro’s decision to publicly denounce the COVID-19 vaccinations has and most likely will continue to have significant impacts on the citizens of his country and their health outcomes ( WHO, 2022a ). In October of 2021 , President Bolsonaro made his stance clear by stating he had “decided not to have it anymore” and further clarifying that while he was not anti-vaccination, he did oppose what he called the vaccine-buying “frenzy” ( Phillips, 2021 ). With over 620,000 deaths in Brazil, as of this writing, a conscientious decision by the political leader of the country to not support efforts to purchase vaccinations is a stark reminder that the decisions of those in power have existential effects on those governed therein.

Yet, the decisions of a vaccine-skeptical leader in South America are not the full story of the global impact and import of the political determinants of health. As a matter of fact, this example does not even begin to highlight the leveraged role that the political determinants of health currently play in the race to emerge on the other side of the COVID-19 syndemic. Consider, as an illustration of such, the inequitable distribution of COVID-19 vaccinations across the global community and the lingering effects of such. Or, as Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, stated in a more succinct fashion, “the unequal distribution of vaccines is not only a moral outrage, but economically and epidemiologically self-defeating” ( WHO, 2021a ). What this means in practicality, as the WHO stated, is that “COVID-19 vaccine inequity will have a lasting and profound impact on socio-economic recovery in low- and lower-middle income countries without urgent action to boost supply and assure equitable access for every country, including through dose sharing” ( WHO, 2021b ). While this dire warning was conveyed by the WHO in July of 2021 , evidence indicates that efforts to stem the tide of inequitable distribution have by and large proven insufficient.

According to the WHO’s Coronavirus (COVID-19) Dashboard, many regions of Africa still significantly trail other parts of the global community in the administration of COVID-19 vaccinations ( WHO, 2022b ). What this highlights is that decisions made at the highest levels of one country can have significant downstream effects on the respective citizens of another country, resulting in the collective exacerbation of health inequities in the broader global community. To put an even finer point on this reality, look no further than the global health worker shortage. The New York Times highlighted the issue during the pandemic, by stating that

the urgency and strong pull from high-income nations—including countries like Germany and Finland, which had not previously recruited health workers from abroad—has upended migration patterns and raised new questions about the ethics of recruitment from countries with weak health systems during a pandemic ( Nolen, 2022 ).

While this trend of mobilizing foreign-trained doctors and nurses in response to COVID-19 will undoubtedly continue to benefit globally wealthy countries, such as those in the Organization for Economic Cooperation and Development (OECD), the draw on human capital will also continue to leave the under-resourced members of the global community further and further behind ( OECD, 2020 ). The fact that regions of the globe that lag in vaccination administration, due in large part to policy decisions made by the globally affluent, must also simultaneously contend with the reduction of their clinical workforce due to the recruitment by those very same globally affluent decision makers, is emblematic of the impact of the political determinants of health beyond borders.

Yet, the impact of the political determinants of health existed before the onset of COVID-19 and extends beyond such as well. Consider, for example, Australia and the “stolen generation.” In the early 1900s, the Australian government adopted a child removal policy birthed from the Aboriginal Protection Act of 1869 mainly geared at the removal of mixed-race aboriginal children from their families, under the false pretense that “full blood” aboriginal people would eventually become extinct after a sharp population decline from European colonization of the region ( Manne, 2008 ). This adoption of an institutionalized apartheid led by British-Australian public servant Auber Octavius Neville, named chief protector of Aborigines, was an attempt by the Australian government to assimilate the indigenous aborigine into society and marry them with people of lighter skin tones over successive generations to “breed out the color” ( Read, 1981 ). The result of this policy left the “stolen generation” with a wide range of adverse health outcomes: poor physical and mental health, including high incidences of substance use, anxiety, depression, PTSD, suicide, absenteeism in school, and poverty ( Allam, 2019 ).

Peering even further back in the annals of time, in the Central American country of Honduras, colonialism by the Spaniards also brought about a similar story and fate to the region. Once a thriving population of a complex mixture of indigenous populations and linguistics, the country is now reduced to a fraction with only about 9% of the total population self-identifying as members of the indigenous community per the country’s latest census ( Quartucci, 2021 ). The Lenca people, who are now the largest indigenous group in the country, mainly live in remote hard-to-reach mountainous areas, presumably as a survival tactic resulting from historical oppression into vassalage or elimination of them all together, by the Spanish settlers in the 1500s; they lack basic services such as running water and latrines, roads, and transportation ( Quartucci, 2021 ). When discussing health and the environment, in particular the role of water and sanitation, the Pan American Health Organization (PAHO) (1997 , p. 14) reports that “there is a tendency to characterize indigenous populations as being similar to poor and marginal urban populations. However, there is little official data on the coverage and quality of water supply and sanitation services in these populations.”. Several organizations also published the following challenges faced by indigenous populations: fluctuating maternal mortality rates (190 – 255 per 100 thousand births) and non-culturally appropriate care ( di Fabio & Almeda, 2006 , pp. 198-199); a decreased life expectancy for both men and women of up to 20 years high incidence of poverty, malnutrition and infectious diseases ( United Nations, n.d. ) , and high incidences of parasitic infections ( PAHO, n.d. ) all contributing to overall poor quality of life for these populations

. Adding to the neglect, the Lenca have also been subject to human rights abuses. In one of the most high-profile cases, at least three instances were reported where indigenous activists were murdered for defending against the building of hydroelectric dams on their lands after the Honduran government passed the Law on the Promotion of Public/Private Alliances in 2010 , which privatized 47 rivers in the country ( Global Witness, 2017 ; Minority Rights Group International, 2018 ; World Bank Group, 2021 ). In this instance, not only did policy propagate the mistreatment of an already vulnerable population on the verge of extinction but its inaction to properly investigate the occurrences is also a passive stance against the situation.

Yet, notwithstanding these historical, and to a certain extent demoralizing, examples of the role of the political determinants of health, there remain even more contemporary moments in history to point to. Consider the multigenerational harm inflicted by the policies of apartheid that were implemented in South Africa. As an in-depth, and still prescient, special report from the New England Journal of Medicine puts it,

in the [decades] since South Africa underwent a peaceful transition from apartheid to a constitutional democracy, considerable social progress has been made toward reversing the discriminatory practices that pervaded all aspects of life before 1994 . Yet, the health and well-being of most South Africans remain plagued by a relentless burden of infectious and noncommunicable diseases, persisting social disparities, and inadequate human resources to provide care for a growing population with a rising tide of refugees and economic migrants ( Mayosi & Benatar, 2014 , p. 1344).

The National Party, which came to power in South Africa in 1948 , made apartheid a state policy and espoused the discriminatory ideology that people of different racial origins could not live together in equality and harmony, often failing to look at the downstream effect this state policy continues to have on health outcomes today ( Reddy, 2021 ).

Taking a more expansive point of view, beyond the scope of nation-state borders, one can even look toward regional policy decisions to see the far-reaching impact of the political determinants of health. Take, for example, the effect that “Brexit” has had on health and health care outside of the United Kingdom. While acknowledging that the principal effects of Brexit on health and health care fall within the United Kingdom, as the Journal of Health Politics, Policy, and Law so effectively demonstrates, it is worthwhile to also consider the external effects of Brexit for health and health care or what has been coined the “Brexternalities” ( Hervey et al., 2021 ). Consider the massive disruption that Brexit has had on health infrastructure. For example, “U.K.-based companies, which supply products across the EU, need to shift regulatory interactions to other member states, so as to secure continued access to the EU’s internal market” ( Hervey et. al, 2021 , p. 185). Or even further, the reality that “pharmaceuticals batch-testing facilities needed to be transferred from the U.K. to the EU” ( Hervey et al., 2021 , p. 186). These are but a few of the reverberating ramifications that have been felt as a result of the upstream decisions to Brexit—all of which will invariably be shouldered by those with the most muted voices in the decision-making process.

In addition, notwithstanding its status as a world leader in developing the latest health care advances as well as for spending on health care, the United States has continued to fall behind other developed countries in health rankings. Even though it spends more on health care than any other country and consumes more than half of the world’s health care resources, the United States has seen increasing mortality and falling life expectancy for people ages 25 to 64, who should be in the prime of their lives ( Achenbach, 2019 ; Zalla et al., 2022 ). Historically, the United States has failed to recognize the importance of supporting universal access to health care along with programs to improve the overall quality of life for every individual. Data on health care and living conditions are important in helping to identify the gaps in care and services and improve the way resources are used to improve health and well-being.

While the positive contributions of big data and data science to society do not go unrecognized, they are also marred by political determinants, as blatantly observed during times of disaster and emergency, such as a pandemic. This is especially true of health data where responsibility of its governance, as The Lancet Digital Health ( 2021 , p. E684) mentions, “must be driven by public purpose, not private profit.” Efforts to inform the public at large and formulate an appropriate response to an emergency or disaster with proper planning and allocation of resources is highly dependent on not data alone, but accurate and comprehensive data.

However, even highly regarded public health entities struggled to produce data that was not only uniform but comprehensive during the COVID-19 pandemic at a national level, much less at a global level. While seemingly simple, this complex task requires a consensus from respective leaders in public health and government, which may be arduous in part due to party politics; it also requires that efforts be coordinated, uniform, and most of all, inclusive.

In the United States, data collection during the COVID-19 pandemic was not standardized and varied at all levels of government, and even across all states. Sociodemographic information such as race and ethnicity, age, and gender, which is crucial not only for leading quality initiatives related to population health but also for identifying under-resourced communities and knowing who requires immediate attention, was missing in many of the reported cases to the CDC Case Surveillance Restricted Access Detailed Data set ( Health Equity Tracker, 2021 ). At the time of writing this article, standardization of race and ethnicity categories for data collection across state and local jurisdictions did not exist, with some states not recording data for American Indian, Alaska Native, Native Hawaiian, and Pacific Islander racial categories, lumping these populations into other groups, causing notable gaps in the data collected. In addition, sex is recorded only as male, female, or other; mental health and physical health such as disabilities is not recorded, leaving noticeable deficiencies in the ability to identify subpopulations.

The lack of disaggregation of big data is just as hurtful as not collecting data all together, as many groups remain misidentified, unidentified, and unaccounted for. Adding to the complexity is that data sets such as the one described are restricted and require the user to undergo a bureaucratic process to obtain access. If and once achieved, the end user must then determine how to unscramble the packaging of the complex data, often requiring subject matter experts in the field of data science and software programming. Each of these hurdles stems from the lack of uniform policies, which have now resulted in the creation of digital determinants of health data.

Through research in the fields of public health, medical sociology, and social epidemiology, it is now well understood and widely accepted that the social determinants of health affect all aspects of the daily lives of humans. In fact, it is known that the social determinants of health directly affect and often even determine individuals’ and communities’ choices about and access to adequate, affordable, and nutritious food options, safe housing, blue and green spaces, reliable and safe transportation, education and literacy, opportunities for economic stability, and sanitation, among other important factors. In addition to genetics and behavior, the direct significance of all the social determinants of health variables and their contribution to health, wellness, and life opportunities have also come to light. The link between the wide range of health risks and outcomes is now clearly demarcated by conditions in the places where people live, learn, work, and play ( Health Equity Tracker, 2021 ). In simpler terms, because of the social determinants of health, one’s zip code is often a stronger determinant of health than one’s genetic code ( Health Equity Tracker, 2021 ).

Health systems are increasingly investing in programs and influencing policies to address upstream drivers of health, which include the macro-level forces that comprise social-structural influences on health and health systems, and the social, physical, economic, and environmental factors that affect health. In the United States, health systems, for example, have mostly invested in addressing the social determinants of health of their patient populations. From 2017 to 2019 , health systems in that country collectively spent $2.5 billion on programs targeting social determinants of health ( Horwitz et al., 2020 ).

What gives rise to the social determinants of health and—more important—why have they disproportionately and detrimentally affected communities for so long? A growing number of health equity scholars, researchers, advocates, and champions support the notion that the social determinants of health are not the fundamental causes of health inequities. Deeply entrenched and pervasive throughout society exist the fundamental instigators or drivers of these unjust and inequitable outcomes called the political determinants of health, which often go undetected, unnoticed, and worse, ignored—despite the incredible driving force they have on all inequities in countries across the world.

Political Determinants of Health Explained

With a baseline understanding of the social determinants of health, the focus then shifts to understanding what the political determinants of health truly are and, more important, how to leverage them to enact sustainable change. Political determinants of health create the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health ( Dawes, 2020 ). Political determinants of health are more than merely separate and distinct from social determinants of health: they serve as the instigators of the social determinants of health with which many people are already well acquainted. While the social determinants are quintessential for understanding why so many disparate groups have historically faced, and continue to grapple with, health inequities, they do not paint the full picture of how these disparities may be addressed. Looking at health through the lens of political determinants means analyzing how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance ( Dawes et al., 2021 ).

Dawes (2020 , p. 44) defined the political determinants of health as “involving the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities.” Dawes (2020 ) also provided a roadmap for advancing health equity for current and future lawmakers, researchers, scholars, and leaders, focusing on three major aspects of the political determinants of health: voting, government, and policy. To move from simply naming inequities to addressing inequities, work must be performed upstream to address the root causes or origination of these inequities. As such, it is important to understand how political determinants of health leave all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with, and suffering from, less access to affordable, reliable health care, worse health outcomes, and greater risk for early and often-preventable mortality. Simply put, this can be viewed as presented in Figures 1 and 2 .

Figure 1. Political determinants of health framework.

Figure 2. How the political determinants of health structure relationships, distribute resources and administer power.

The political determinants of health are, unfortunately, influential in creating relationships between government and policy that result in inequitable outcomes (laws, rules, or regulations that oppress one or more populations), allowing for a few to remain in power and to determine which communities receive vital resources necessary for their well-being and optimal living.

The political determinants of health framework depicts interconnecting or circular arrows demonstrating that political determinants of health operate simultaneously in ways that mutually reinforce one another and concurrently impact or are impacted by a continuum of interacting barriers and interventions. Health equity champions must overcome those barriers and leverage interventions to advance health equity–focused policies and address other competing and equally complex determinants of health. This is a continual strategic process that does not end once a policy is realized but requires constant monitoring and engagement by advocates to determine whether a policy or governmental action is positively or negatively affecting the determinants of health and advancement of health equity ( Dawes, 2020 ).

To explain how these determinants have operated, consider all of the components in a theatrical production that are needed to deliver a performance. The props you see on stage are crucial in the storytelling; they complement the actors’ performances, help set the scene and bring the characters to life, and help draw in the audience for a full immersive experience. Translated to real life, the actors represent each living person, the theatrical performance represents each person’s life, while the props are the social determinants of health impacting every person. Yet, all the while, behind the scenes lies a more crucial and complex operation: the coordination of the props. It is the stage master or coordinator who is responsible for not only securing all the necessary props, but also ensuring that all props are properly queued up at the right point in time of a performance. Imagine if the stage master or coordinator incorrectly queued up a prop, never queued up the prop or, worst of all, forgot a prop altogether. Imagine the impact this would have on the actor, the storytelling, and the overall theatrical performance. Although the stage master or coordinator is never seen or acknowledged, their presence or lack thereof is widely seen and felt and provides a lens and foundation through and upon which the audiences interpret and experience the performances. Their role can contribute to the overall success or detriment of a theatrical performance.

The stage master or coordinator represents the political determinants of health, which—in real life—translates to three major drivers: voting, government, and policy. Together, these three determinants are the most upstream factors of all, which are in concert “behind the scenes,” orchestrating a major production of interrelated downstream factors (the social determinants of health) affecting the populace and governmental and commercial interests, and historically driven by policies based on moral, performance, economic, and national security interests and arguments. The political determinants of health push and pull at the ropes that hoist the props (or, in this example, the social determinants of health) in our lives and help to concretize structural, institutional, interpersonal, and intrapersonal barriers at their intersections.

Collectively, political determinants of health contribute to the imbalance found in each country’s scale of equity, affecting the ability of each human being to live most optimally in a society that champions and upholds equality, equity, and justice over disparity, discrimination, and inequity. As public health leaders, scholars, and others continue to grapple with the lasting effect of the pandemic on health, it is of vital importance that the health inequities that have historically plagued the country and continue to manifest among the population today are acknowledged, understood, and addressed.

Historical Context: The United States as a Case Study

To understand the complexities of the political determinants of health and the vast and systemic nature of intractable health inequities that have plagued our society, it is important to understand the historical context in which these inequities were concretized in our structures, systems, and communities over time. Anecdotal evidence strongly suggests that they are the key drivers that were germinated hundreds of years ago, nourished in the soils of explicit and implicit racism and discrimination, and have been allowed to not only create and sustain, but to grow and exacerbate the very social drivers that health equity and justice champions seek to investigate and eliminate, to close the most pressing health and health care gaps in developed and developing countries.

In the United States, the political determinants of health inequities first reared their head in 1641 when the first legal code to legalize slavery was established by lawmakers in New England. It started with the development, introduction, passage, implementation, amendment, and enforcement of the Body of Liberties law, written and supported by policymakers in each of the colonies who worked with commercial interests that were intent on maintaining their business model, which relied on slavery. It continued with the creation and advancement of additional “facially discriminatory” policies throughout the next 300 years that explicitly prohibited Black and Indigenous populations from addressing their “social determinants of health” needs, including prohibiting these groups from raising their own food, earning their own money, or learning to read and write; limiting their ability to move; and denying them the right to vote and engage in civic discourse on matters that directly impact their health and lives. The result was that it segregated them into communities or reservations unfit for healthy outcomes, among other extremely restrictive policy measures. The negative pervasive consequences of the political determinants of health on minoritized and marginalized groups in America as well as in other countries have been profound.

Today, the impact of “facially neutral” policies on these groups at local, state, federal, and international levels can be observed quite glaringly. In fact, examples of this type of unjustness can be observed in runs throughout so many laws that often exist and are enforced below the radar of equity and justice. Examples include “facially neutral” policies that—once enacted—resulted in diminishing access to safe, affordable housing and displacing hundreds of thousands of racial and ethnic minorities; infrastructure policies that disproportionately burden communities of color; transportation policies that created new and exacerbated existing disparities in racial and ethnic health outcomes; and policies limiting access to health care services, which have collectively resulted in “deserts” and “poverty taxes” in these communities.

Contemporary Impact: Dissecting the Political Determinants of Health

The compounding effects of other factors leading and driving health inequities can now be observed, along with the interrelationships among them; most notably, the COVID-19 pandemic has revealed a long-standing history of social injustices and inequities entrenched in all aspects of society, including its systems. The impacts of slavery, segregation, apartheid, racism, classism, sexism, ableism, and caste have been associated with long-term effects on nearly all health disparities seen today, including premature and often preventable mortality across many diseases and injuries. It is not by chance that certain populations experience higher premature death rates than others, or that women of certain populations experience higher pregnancy-related deaths, or that factors such as poverty, crowded housing, inadequate transportation, food insecurity, medical deserts, and other community attributes associated with social vulnerabilities put a community at higher risk for increased adverse outcomes.

Systemic discrimination still exists, both in plain sight and in more subtle ways. It festers in institutions and systems that have been slow to change. It manifests quietly in unconscious biases and entrenched perceptions. The hurt it causes to communities of color, other vulnerable populations, as well as to society, persists. The negative and deleterious health consequences of political determinants of health are, arguably, equal opportunity offenders because, as Dr. Sandro Galea has stated, “politics shapes and is shaped by underlying social, economic, cultural, and geographic forces” ( Galea, 2022 , pp 101). As such, political determinants of health leave all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with, and suffering from, less access to affordable, reliable health care, worse health outcomes, and living at greater risk for early and often-preventable mortality.

This begs the question: How have political determinants of health instigated, perpetuated, or exacerbated the poorer health outcomes and lower life expectancies among vulnerable, under-resourced, and marginalized populations in the United States, the United Kingdom, Canada, Australia, Brazil, France, Mexico, Venezuela, and Colombia among many other nations? How did the unequal structural conditions that people are born into, live in, and die in, originate and how have they been sustained?

Understanding this requires individuals to grapple with how the political determinants of health inequitably distribute social, medical, and other determinants and create structural barriers to equity for population groups that lack power and privilege. For virtually any social determinant of health to which one can point, there was some preceding legal, legislative, policy, or regulatory decision that was first made, resulting in the subsequent social determinant. These decisions are the political determinants of health, which have significant influence on health factors. Collectively, these determinants and drivers, experienced across the life course, are what have given way to racism and health inequities in countries around the world.

Voting as a Political Determinant of Health

In many countries, voting is deemed a fundamental civic duty, and yet many individuals fail to recognize or take for granted voting’s impact on their health, well-being, and life expectancy. It is impossible to disentangle the relationship between many of the political processes, strategies, tactics, and rules and the impact they have had and continue to have on health inequities and outcomes. Voting empowers individuals of a society to put in place and/or bypass decision makers ( Dawes, 2020 ). Better explained, voting affords all, at an individual level, a voice to engage in policy solutions for issues directly impacting not only themselves but their respective communities. It extends a representation of themselves and their interests into government by placing like-minded individuals aligned with their views, whether religious, economic, political, or cultural in nature, in seats of government charged to act in their best interest. Yet despite voting being a significant aspect of the political determinants of health, many fail to make the connection between voting and their own health outcomes and premature deaths, which are disguised behind decisions embedded within social determinants directly impacting their daily living and their surrounding communities. Several factors exist that act as individual scenarios but also add to the interplay of the political determinants, that when considered together, explain the governing dysfunction and mistrust by the public.

While some voluntarily choose to exclude themselves from this process (voter apathy), other population groups have been intentionally excluded from this process. Over the years, opportunities for civic engagement have been stymied by continual efforts to restrict, suppress, subvert, or obstruct voting by groups who have limited power and privilege. The overt exclusion from civic engagement through historical and contemporary methods of gerrymandering, which include coercive attempts to restrict ballot access to citizens on the downside of elite American privileges, continues to perpetuate inequities. Poll taxes, voting restrictions, such as voter identification laws, purging voter rolls of irregular voters, minimizing the opportunities for early voting, requiring voter identification, and closing or moving polling places farther away from voters, have disproportionately affected racial and ethnic minority communities and lower-socioeconomic status individuals ( Dawes, 2020 ). Yet, it is known that voting rights are essential for creating and advancing health equity. As voter suppression occurs, the individuals most impacted by inequities, who need a fair adjudication of their issues, are the same individuals who find themselves locked out of the political system ( Dawes, 2020 ).

Money is another factor that impacts the political determinants of health in countries. For any candidate to participate in the political process, especially elections, an extensive amount of money goes toward campaigning alone. In the United States, both congressional and presidential spending for the 2020 election surpassed, and nearly doubled, the previous election, making it as the most expensive in the nation’s history at $14 billion ( OpenSecrets.org, 2020 ). This scaling up of campaigning is another barrier for an ordinary citizen to hold a seat in government. Lobbying expenditures in America also act as a significant financial barrier to campaigning, having reached a total of $3.49 billion in 2020 ( Duffin, 2021 ). Depending on the policy issue and its implications, large amounts of effort and money can be spent to assure a political win, backed by large corporations, agencies, and special interest groups. Indisputably, lobbying can help sway the health equity needle from pointing to a true north if advocates’ health equity agendas are out of alignment with commercial interests and government investment values.

Demographics

This discussion on political determinants of health would not be complete without considering the increasing and shifting demographics toward a rise in racial and ethnic diversity within developed countries owing to globalization ( Jensen et al., 2021 ). In the United States, for example, although progress has been made relative to diversifying the federal government, there has been a growing physical disconnect between those represented and those who represent them, leading to an ever-widening gap in health inequities and a dearth of policies and programs addressing them ( Schaeffer, 2021 ). This does not even account for the potential growth that is projected to occur due to global migration propagated by protracted conflicts, climate change, and environmental degradation, which will intensify the need for equity-focused and inclusive public policies ( United Nations, n.d. ). Of equal concern is the process of congressional apportionment, or representation based on population size. With the dramatic increase in the U.S. population and no more addition of seats to the House of Representatives, one individual is said to be representative of an even larger population than before ( Desilver, 2018 ). In view of both facts, the question arises: To what extent can one representative truly be representative of so many?

The fourth major factor affecting the political determinants of health is a powerful tool that, while acknowledged as a symbol of progress and advancement globally, has also been weaponized in many instances into a destructive force: technology. Collectively, technology is recognized by its many faces, such as big data, television, the Internet, and, arguably the most popular during the past year, the multitude of social media platforms such as LinkedIn, Twitter, Facebook, Instagram, and TikTok. Though it has many great uses, it has also aided in counterproductive efforts such as abetting the rapid spread of misinformation as well as allowing for the disruption and interference of crucial processes, such as in the electoral process ( Dawes, 2020 ). In this light, technology can either aid or hinder civic education and advancement. As a nation working to remedy and improve upon its current state of affairs, this is one aspect that the United States, or any country for that matter, cannot afford to undermine, much less ignore.

Government as a Political Determinant of Health

Another political determinant of health is government. Although key, voting alone is not sufficient to meaningfully address inequities ( Dawes, 2020 ). While the populace of a country may understand the process associated with voting and its impact, government and its complex inner workings seem to be far less understood—understandably so, whether in America or in other societies across the globe. Government, like the rest of society, is not exempt from partaking and contributing to the socio-ecological model that exists in society; while simultaneously dealing with structural barriers, government must also finesse the interplay between intrapersonal, interpersonal, and institutional relationships brought about by policy.

Individually considered, each is a contributing factor or can act as a barrier to health equity and is the source of the scarcity of inclusive and equitable policies. Collectively, this interplay adds another layer of difficulty to expand the inclusivity in policies when considering the interplay between structural and other forms of barriers sanctioned by the government through the introduction or non-introduction, the enactment or non-enactment, the enforcement or non-enforcement, or the clawback or repeal of policy.

Unfortunately, the list of challenges within government alone is extensive. Consider again other socioeconomic factors of the demographics of those seated in the United States’ federal government positions; most are far-removed from the people they are thought to represent. Most policymakers are more educated and affluent than the population they represent, making the opportunity for most Americans to sit at this level of government very distant ( Chinoy & Ma, 2019 ). The lack of representation from all walks of life—especially those who experience inequities, contributes to the dearth of inclusivity and equitable policies generated by policymakers. The result, instead, is a government that mirrors and operates with the social biases and social maladies found in society at large: racism, discrimination, misogyny, ableism, and homophobia, to name a few.

Policy as a Political Determinant of Health

Policy as a political determinant of health serves to concretize government decisions. However, it is important to note that this determinant alone should not be revered as the ultimate, but as part of the panoply of all political determinants acting in tandem ( Dawes, 2020 ). An initial success on this front does not necessarily equate to a final victory, as efforts geared toward the first two political determinants may be underway to quash policy. Thus, it is important to note that a strategic approach as well as advocacy efforts also play substantial roles in successfully aiding the passage of a policy and, ultimately, a political interest.

This system has rarely valued each group equally or realized the long-term implications of policies on the health of its citizenry. A slew of health problems (high obesity rates, maternal mortality, infant mortality, gun violence, depression, opioid addiction, substance use disorders, diabetes, heart disease, cancer, HIV/AIDS, and many more)—including COVID-19—can be firmly linked to political action or inaction ( Dawes, 2020 ). In American history, the combination of having proponents or advocates of a policy and well devised arguments has proved to successfully support the passage of policy; four arguments in particular, morality, performance, economic security, and national security, have been instrumental to its passing. Undoubtedly, advocacy is a vital role in the continual strategic process serving as a litmus test for policy and governmental action, and their combined effects on advancing health equity ( Dawes, 2020 ).

Jessica’s Story: A Case Study

A pregnant 19-year-old woman, Jessica is simply trying to survive and work toward a better future for herself and her growing child in a less than desirable environment. She lives in an apartment in a low-income neighborhood. Convenience stores and fast-food restaurants dot every intersection, sidewalks are scarce, city buses do not run through her community, health care providers refuse to operate in the community owing to poor reimbursement rates from Medicaid, and the local schools are failing.

Each of these neighborhood conditions was politically determined. Politicians determined whether to create and keep housing segregation in place and whether to expend resources to build sidewalks, parks, or recreational facilities in the community so individuals can walk, play, and exercise. Politicians decided whether to create a bus route through the community to connect it with other more resourced communities or whether to incentivize grocery stores to operate in the community and provide access to fresh fruits, vegetables, and meat.

When community members decided to take matters into their own hands by trying to establish a community garden and operate a farmers’ market, politicians failed to issue a permit allowing them to proceed with the project. Politicians also influenced decisions to cover obstetric, gynecologic, and other health services under government health insurance programs or to increase reimbursement rates to incentivize providers to serve poorer populations. Historical redlining has created many of these microcosms of vulnerable communities within even flourishing cities and neighborhoods ( Rothstein, 2017 ).

Jessica’s dilemma highlights the trickle-down effect of policies put into place by elected officials that do not consider the humans who are bound to the regulations they create. These decisions made by policymakers impact Jessica’s birth experience: Due to a lack of insurance, she gives birth to a child 9 weeks prematurely, owing to undiagnosed preeclampsia, and is not given the tools to help her or her child to thrive and grow as a healthy family. Far too often, Jessica’s story is a reality for Black, Hispanic/Latin(o/a/x), and Indigenous populations. The systemic neglect experienced by disadvantaged communities restricts and limits their ability to control the air they breathe, the food they eat, access to transportation, and the quality of their health care. It is up to those in power to make more ethical choices and decisions, and to remain cognizant of the fact that these are living, breathing, human beings who are being disregarded and neglected by the very political structures established to protect minoritized and marginalized population groups.

No two political systems are ever exactly alike, regardless of their definitional classification. This becomes irrefutably true when you drill down further and begin to consider the differing machinations of more local governance. Even the United States of America is composed of fifty distinct states, each with slightly different political systems owing to differing interests and stimuli. And yet, even though no two systems are ever exactly alike, every political system has the shared propensity and capability of impacting the health outcomes of its citizenry due to the political determinants of health. By first understanding that each and every governmental institution has the potential to leverage the political determinants of health, either for the benefit or to the detriment of the people it exists to serve, only then can one begin the arduous process of ensuring that these determinants are in fact prioritized for the greater good.

If, as the World Health Organization describes it, health equity is the absence of avoidable or remediable differences in health among groups of people, then it can logically be concluded that the presence of health inequities is indeed an avoidable outcome ( WHO, 2018 ). Put more succinctly, actionable steps can and should be taken to remedy health inequities. Specifically, those steps begin with the act of leveraging the political determinants of health. While the political determinants of health may be unfamiliar territory for some, the United States has a long history of leveraging them to exacerbate disparities, which means a playbook already exists for leveraging them to ameliorate disparities.

The social, environmental, and other determinants of health were designed, implemented, and perpetuated by political, legislative, regulatory, or legal decisions. The social determinants, environmental determinants, health care determinants, even behavioral determinants of health all owe their existence and pervasiveness to the political determinants of health. As such, it is incumbent upon researchers, leaders, and community advocates to more effectively highlight the nexus between the political determinants of health and their downstream impacts, in order to make the compelling case for prioritization of health equity. Health equity leaders must be as well-versed in the political determinants of health as they are in every other determinant if they are to ever truly achieve a more equitable tomorrow for all population groups around the globe.

Further Reading

• Brown, M. , & De Maio, F. (2021). Unequal cities: Structural racism and the death gap in America’s thirty largest cities . Johns Hopkins University Press.
• Dawes, D. E. (2020). The political determinants of health . Johns Hopkins University Press.
• Galea, S. (2022). The contagion next time . Oxford University Press.
• Otterson, O. P. , Dasgupta, J. , Blouin, C. , Buss, P. , Chongsuvivatwong, V. , Frenk, J. , Fukuda-Parr, S. , Gawanas, B. P. , Giacaman, R. , Gyapong. J. , Leaning, J. , Marmot, M. , McNeill, D. , Mongella, G. I. , Moyo, N. , Møgedal, S. , Ntsaluba, A. , Gorik Ooms , Bjertness, E. , . . . Schee, I. B. (2014). The political origins of health inequity: Prospects for change . The Lancet–University of Oslo Commission on Global Governance for Health , 383 , 630–667.
• Papamichail, A. (2021). The global politics of health security before, during, and after COVID-19 . Ethics & International Affairs , 35 (3), 467–481.
• Zambrana, R. , & Williams, D. R. (2022). The intellectual roots of current knowledge on racism and health: Relevance to policy and the national equity discourse . Health Affairs , 41 (2), 163–170.
• Achenbach, J. (2019, November 26). U.S. life expectancy: Americans are dying young at alarming rates . The Washington Post .
• Allam, L. (2019, June 12). Trauma and poverty transferred directly to children of stolen generations—Study . The Guardian .
• Bardhan, M. , Hasan, M. M. , Ray, I. , Sarkar, A. , Chahal, P. , Rackimuthu, S. , & Essar, M. Y. (2021). Tuberculosis amidst COVID-19 pandemic in India: Unspoken challenges and the way forward . Tropical Medicine and Health , 49 , 84.
• Benjamins, M. R. , De Maio, F. , & Morita, J. (2021). Unequal cities: Structural racism and the death gap in America’s largest cities . Johns Hopkins University Press.
• Chinoy, S. , & Ma, J. (2019, January 26). Paths to power: How every member got to Congress . The New York Times .
• Dawes, D. E. (2016). 150 years of ObamaCare . Johns Hopkins University Press.
• Dawes, D. E. , Kirby, R. S. , Dunlap, N. J. , & Valle, M. A. (2021). An overview of maternal and child health history: A political determinants of health perspective. In R. S. Kirby & S. Verbiest (Eds.), Kotch’s maternal and child health: Problems, programs, and policy in public health (pp. 81–96). Jones & Bartlett Learning.
• Desilver, D. (2018, May 31). U.S. population keeps growing, but House of Representatives is same size as in Taft era . Pew Research Center.
• di Fabio, J. L. , & Almeda, R. (2006). Health of the indigenous peoples of the Americas Initiative . Pan American Health Organization.
• Digital technologies: A new determinant of health [Editorial]. (2021). The Lancet Digital Health , 3 (11), E684.
• Duffin, E. (2021, March 4). Total lobbying spending in the United States from 1998 to 2020 (in billion U.S. dollars) . Statista.
• Forrester, S. , Jacobs, D. , Zmora, R. , Schreiner, P. , Roger, V. , & Kiefe, C. I. (2019). Racial differences in weathering and its associations with psychosocial stress: The CARDIA study . SSM–Population Health , 7 (100319), 1–8.
• Galea, S. (2021). The contagion next time . Oxford University Press.
• Geronimus, A. T. , Hicken, M. , Keen, D. , & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States . American Journal of Public Health , 96 (5), 828–832.
• Global Witness . (2017, January). Case study 1: The National Party president and her links to illegal dam .
• Health Equity Tracker . (2021). Methodology .
• Hervey, T. , Antova I. , Flear, M. L. , McHale, J. V. , Speakman, E. , & Wood, M. (2021). Health “Brexternalities”: The Brexit effect on health and health care outside the United Kingdom . Journal of Health Politics, Policy and Law , 46 (1), 177–203.
• Horwitz, L. I. , Chang, C. , Arcilla, H. N. , & Knickman, J. R. (2020). Quantifying health systems’ investment in social determinants of health, by sector, 2017–19 . Health Affairs , 39 (2), 194–196.
• Jensen, E. , Jones, N. , Rabe, M. , Pratt, B. , Medina, L. , Orozco, K. , & Spell, L. (2021, August 12). 2020 U.S. population more racially and ethnically diverse than measured in 2010 . United States Census Bureau.
• Manne, R. (2008, March 5). Sorry business: The road to the apology. The Monthly .
• Mayosi, B. M. , & Benatar, S. R. (2014). Health and health care in South Africa—20 years after Mandela [Special Report]. The New England Journal of Medicine , 371 , 1344–1353.
• Minority Rights Group International . (2018, May). Minorities and indigenous peoples in Honduras: Lenca .
• Nolen, S. (2022, January 24). Rich countries lure health workers from low-income nations to fight shortages . The New York Times .
• OpenSecrets.org . (2020, October 28). 2020 election to cost $14 billion, blowing away spending records .
• Organization for Economic Cooperation and Development . (2020, May 13). Contribution of migrant doctors and nurses to tackling COVID-19 crisis in OECD countries .
• Pan American Health Organization . (1997, December 15-17). Indigenous peoples initiative meeting; strategic orientations for the development of the health of indigenous peoples initiatives .
• Pan American Health Organization . (n.d.). Honduras expands deworming coverage of children in remote communities as part of vaccination campaign .
• Phillips, T. (2021, October 13). President of Brazil says “it makes no sense” for him to be vaccinated . The Guardian.
• Quartucci, S. (2021, June 3). Honduras-Indigenous territories and governance . Latina Republic .
• Read, P. (1981). The stolen generations: The removal of Aboriginal children in New South Wales 1883 to 1969 (6th ed.). New South Wales Department of Aboriginal Affairs.
• Reddy, E. (2021). The struggle against apartheid: Lesson’s for today’s world . United Nations Chronicle.
• Rothstein, R. (2017). The color of law: A forgotten history of how our government segregated America . Liveright.
• Schaeffer, K. (2021, January 28). Racial, ethnic diversity increases yet again with the 117th Congress . Pew Research Center.
• Smedley, B. D. , Stith, A. Y. , & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care . Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, National Academies Press.
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• Zalla, L. C. , Mulholland, G. E. , Filiatreau, L. M. , & Edwards, J. K. (2022). Racial/ethnic and age differences in the direct and indirect effects of the COVID-19 pandemic on US mortality . American Journal of Public Health , 112 (1), 161–162.

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PESTEL Analysis of India: Political Factors

Economic factors, social factors, technological factors, environmental factors, legal factors, education system within india, pre-school education, secondary education, higher education.

India is one of the world’s most powerful economies. India’s capital is New Delhi. Two major nations border it: China and Pakistan. Bangladesh, Myanmar, Nepal, Bhutan, and Sri Lanka are some of the neighboring nations. India is one of the largest countries in the world. It should also be noted that the political situation in the country is relatively stable. However, in foreign policy, India has several border disputes with China and Pakistan regarding Kashmir. In addition, there was a particular shift in the domestic political situation in 2019, which is connected with the law on citizenship (Wajid & Zafar, 2021). The fact is that in India, it was forbidden to grant citizenship to refugees from other countries who are Muslims. This event led to protests inside the country.

Despite this, democratic views at the government level are quite highly valued in India. Consequently, there is a separation of powers and civil rights among the population (Jain, 2017). This fact is quite significant since the political climate is one of the criteria for attracting foreign investment. The main problem of India is also the high level of corruption in the country (Jain, 2017). This fact slows down the potential for economic growth in the country and is also a factor of scaring off foreign investment. However, the country is experiencing increased political awareness of this situation both among the population and among the heads of government, which should lead to positive changes.

India is one of the largest economies in the world in terms of GDP. According to the data, the GDP is about 2.5 trillion dollars (Dahiya & Kumar, 2020). However, based on the current situation around the world, India is also experiencing various problems. First, it is a drop in the level of purchasing power and consumer demand. Secondly, it should be noted that the lockdown in 2020 led to several sad consequences. So, about 122 million people lost their jobs (Dahiya & Kumar, 2020). However, there are also positive aspects. India occupies a leading position in some areas of the economy.

India is the seventh-largest country in the world in terms of coffee production and supply. Also, this country is one of the leaders in the agricultural sector. Investments in this sector should amount to about 120 billion dollars by 2025 (Kumar, 2020). The critical export areas for India are pharmaceutical products, jewelry, and transport equipment. In the field of import, India needs to purchase various electronics, gold and silver, and fuel. The main trading partners are China, the United States, and the United Arab Emirates (Kumar, 2020). In addition, India is one of the fastest-growing countries. Consequently, the domestic market of the country represents many opportunities for foreign companies. The main sectors where there is significant growth are computer technology, infrastructure, and medicine.

India is a relatively large country with a population of more than 1.3 billion people (Ghosh, 2019). This factor presents many opportunities for foreign companies, as India provides a reasonably wide range of consumers. Also, this country is of interest for cheap labor, which is also a factor in attracting foreign capital. In addition, India is a country with a diverse population by nationality, language, and religion (Ghosh, 2019). Also, this country is known for its unique sport called cricket, which is quite an attractive factor. Every year, the middle class of the population in India is increasing. However, at the moment, there are problems with poverty and health care.

India is a reasonably technologically developed country. According to some reports, it may even be among the top three leaders in terms of technical equipment of countries (Benedexa, 2020). This fact is one of the main ones in the issue of attracting foreign capital. Thus, many tech giants are opening their divisions in this country. These companies are Facebook, Apple, Microsoft, and Amazon, which annually invest billions of dollars in this area of the Indian economy (Benedexa, 2020). All this leads to the fact that India is one of the leading suppliers of IT specialists worldwide. This is due to the fact that the country has a reasonably advanced IT infrastructure, which leads to the emergence of a large number of highly qualified programmers and other employees. Thus, India is quite an attractive place to invest in e-commerce, software, and mobile applications.

It is worth noting that the accelerated technological progress of any country is associated with the risk of environmental problems (Lokhwandala, 2020). India is no exception in this case and faces such a number of problems as air pollution, water pollution, which are associated with a considerable amount of garbage in the waters of India (Jacob, 2020). There are also problems with frequent flooding and forest destruction. These problems should be provided for doing business since foreign specialists may find life difficult in such conditions. However, despite this, there are also positive aspects. India is quite an attractive place for tourists due to its unusual flora and fauna. In addition, India is famous for its unusual traditional cuisine.

Equal opportunity for everyone, advertising, discrimination legislation, copyright law, consumer rights, and other legal factors are among them. They are feasible, particularly for foreign businesses looking for a market in India. Companies must follow the regulations and legislation that are specific to each country or location where they do business (Jain, 2017). Recent changes in recycling, employment, and discrimination legislation may have an impact on the company’s pricing and labor expenses (Jacob, 2020). Foreign brands have more possibilities to operate in the region because of the government’s flexible regulations on foreign commerce.

The education system in India has been undergoing significant changes in the direction of development and improvement over the past decades. The reason for this is the rapid growth of the country’s economy and an increase in the need for qualified scientific and working specialists. Much attention is paid to all levels of education — from preschool to higher education, getting a good education and a decent specialty among the country’s population is one of the urgent tasks of life (Gupta, 2019). Studying at higher educational institutions in India is becoming increasingly popular among international students (Aithal, 2020). Moreover, there are several traditional ways to get an education for free, not only higher but also postgraduate.

The educational system of India includes several stages: preschool education; school; secondary vocational education; higher and postgraduate education with academic degrees (bachelor, master, doctor). Accordingly, according to the types of education in India, it is divided into secondary, high school, vocational, higher, and additional education (Aithal, 2020). The non-state educational system operates under two programs. The first one provides for the training of schoolchildren, the second one for adults. The age range is from nine to forty years. There is also an open education system, under which several open universities and schools operate in the country.

Traditionally, in India, young children have always been under the supervision of mothers and relatives. Therefore, the system of kindergartens in this country never existed. The problem had become acute in recent decades when both parents often began to work in the family (Aithal, 2020). Therefore, additional groups were created everywhere in schools, acting on the principle of preparatory classes. As a rule, preschool education begins at the age of three. The training takes place in a playful way. It is noteworthy that at this age, children begin to learn English (Aithal, 2020). The process of preparing for school lasts one to two years.

School education in India is built according to a single scheme. The child begins to study at school from the age of four. Education in the first ten years (secondary education) is free, compulsory, and carried out according to the standard general education program (Gupta, 2019). If the program is the same for everyone in India’s first stage of school education, then when students reach the age of fourteen and go to high school, they choose between fundamental and vocational education (Aithal, 2020). Accordingly, there is an in-depth study of the subjects of the chosen course. Preparation for admission to universities takes place in schools. Students who have chosen vocational training go to colleges and receive specialized secondary education. School education is conducted six days a week (Aithal, 2020). The number of lessons varies from six to eight per day. Most schools have free meals for children. There are no grades in Indian schools. However, mandatory school-wide exams are held twice a year, and national exams are held in high schools.

Higher education in India is prestigious, diverse, and popular among young people. More than two hundred universities are operating in the country, most of which are focused on European education standards (Gupta, 2019). The higher education system is presented in the European three-stage form. Depending on the duration of their studies and the chosen profession, students receive bachelor’s, master’s, or doctor’s degrees (Aithal, 2020). In recent decades, due to the steady development of the Indian economy, the number of engineering and technical universities has increased. The Indian Institute of Technology and the Institute of Management are among the most attractive and worthy here. The share of graduates of humanities in India is about 40 percent (Aithal, 2020). Along with traditional universities, there are many specialized higher educational institutions in the country, focusing on native culture, history, art, and languages.

Aithal, P. (2020). Analysis of the Indian national education policy 2020 towards achieving its objectives. International Journal of Management, Technology, and Social Sciences, 5 (2), 19-41.

Benedexa, A. (2020). Technological entrepreneurship and dynamic entrepreneurial capabilities in Indian IT industry. International Review of Business and Economics, 4 (1), 148-54.

Dahiya, S., & Kumar, M. (2020). Linkage between financial inclusion and economic growth: An empirical study of the emerging Indian economy. Vision, 24 (2), 184–193. Web.

Ghosh, B. (2019). Study of Indian society and culture: Methods and perspectives. Kerala Sociologist, 47 (1), 13-29.

Gupta, S. (2019). Changing trends in Indian education system: Merits and demerits. International Journal of Innovative Technology and Exploring Engineering, 8 (4), 15-16. Web.

Jacob, M. (2020). Actors, objectives, context: A framework of the political economy of energy and climate policy applied to India, Indonesia, and Vietnam. Energy research and Social Science, 70 , 11-17. Web.

Jain, R. (2017). Public sector enterprise disinvestment in India: Efficiency gains in a political context. Journal of Asian Economics, 53 , 18-36. Web.

Kumar, G. (2020). Foreign direct investment and Indian economy. Journal of Commerce, Economics and Management, 1 (1), 10-15.

Lokhwandala, S. (2020). Indirect impact of COVID-19 on environment: A brief study in Indian context. Environmental Research, 188 , 109-118. Web.

Wajid, M. A., & Zafar, A. (2021). PESTEL Analysis to identify key barriers to smart cities development in India. Neutrosophic sets and Systems, 42 , 39-48.

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Political Factors

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1. What Political factors explain Indonesia’s poor economic performance? What economic factors? Are these two related?

Political factors are corruption and red tape, absolutism and crony capitalism. Economic factors are poor infrastructure and fleeing of foreign companies from the country decreasing the foreign investments in the country and increasing the unemployment rate in the country. The political and economic factors that hinder growth in Indonesia are entangled.

2. Why do you think foreign firms exited Indonesia in the early 2000’s? What are the implications for the country? What is required to reverse this trend?

I think the foreign firms started exiting Indonesia due to corruption, business costs, poor infrastructure, unreliable legal system, stagnating economy, uncontrolled crime. Some foreign firms did invest, but eventually they left as all their profits were evaporated by giving bribes to the officials. Even though there was an anti-corruption drive, it had no power and even the political leaders didn’t care as they themselves were so corrupt. Also Indonesia lagged behind its neighboring countries like China, India, Malaysia and Thailand which encouraged the foreign firms migrating to these countries. All these resulted in an economic stagnation increasing the unemployment rate, fall in GDP.

This can be reversed by curbing the corruption, reducing the paperwork associated and speeding up the processes, investing in domestic infrastructure by improving roads and electricity. People should elect good leaders who could bring free market trade and avoid favoritism. Privatizing business processes. Increasing the officials salaries which would make them not to expect corruption.

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Home — Essay Samples — Social Issues — Discrimination — Political Violence, Its Definition, Forms, And Factors

Political Violence, Its Definition, Forms, and Factors

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Published: Mar 18, 2021

Words: 1646 | Pages: 4 | 9 min read

Works Cited

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• Kalyvas, S. N. (2006). The Logic of Violence in Civil War. Cambridge University Press.
• Mueller, J. (2017). Terrorism, Security, and Money: Balancing the Risks, Benefits, and Costs of Homeland Security. Oxford University Press.
• Oberschall, A. (2000). The Manipulation of Ethnicity: From Ethnic Cooperation to Violence and War in Yugoslavia. Columbia University Press.
• Pape, R. A. (2005). Dying to Win: The Strategic Logic of Suicide Terrorism. Random House.
• Tilly, C. (2003). The Politics of Collective Violence. Cambridge University Press.

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Political Factors

Essay by xiaoray   •  July 28, 2016  •  Essay  •  858 Words (4 Pages)  •  947 Views

Essay Preview: Political Factors

Election of government had begun in 2010 as part of “Seven-step road map to democracy” that planned by Thein Sein. The president seat is taken by Htin Kyaw who won against Aung San Sung Kyi (Sonawane, 2016). Through this president election it shows that Myanmar is trying to become democratic country. Democracy is political system in which government is by the people, exercised either directly or through elected representative (Charles W. L. Hill). During military regime, many company had invested in Myanmar market as government relaxed the barriers of entering (The Economist, 2016). After few years later, many company starting to retreat from this market as there are many political issue that could affect their business. Current political issue is starting to become more stable compare to last time. As the political is stable, BAT could be free from involvement of government agency such as the production, the price of product and so on. There is a policy issue by Myanmar Investment Commission stated that economic activities that prohibited for foreign invest such as beer, tobacco industry and so on. Those foreign invest must undertake through a joint venture with Myanmar national and those require compliance with certain condition by sector (Bernardo 2016). BAT will be needed a joint venture with local Myanmar company based on the policy issue by Myanmar Investment Commission as BAT is in tobacco industry. On the positive side, BAT could reduce their risks in entering a foreign country by having joint venture with local company such as culture and communication. Joint venture partner can provide useful information when BAT doing preparation of entering the target market. According to the Union tax law, in 2015, cigarette tax rate rise from 100 percent to 120 percent while taxes on other tobacco products were raised to 60 percent from 50percent. Taxes rate is based on the factory value products which means the cost of production and including taxes the total cost will be low compare to others countries market (Ttwin, 2015). This taxes rate will give BAT advantage as BAT produce foreign brand cigarette to fight with local brand. It will be affordable for local people. For the first 3 years including the year of commencement, BAT will be granted exemption from income tax under Foreign Investment Law in Myanmar (Foreign Investment Law, 2016).

Economical factor

Myanmar is choosing as target market by British American Tobacco (BAT) because of their stable economic condition despite that Myanmar had floods disaster in 2015. Myanmar GDP at market is increasing from 58.653 billion at 2013 to 64.866 billion at 2015 (Refer to Appendix 1) (World Bank (1), 2016). By previous statement, we can see that Myanmar economic is steadily increase as it is an ideal condition for investment. Myanmar economic growth in 2015 eased to 7 percent in 2015/2016 (Refer to Appendix 2) due to severe floods in July 2015 (World Bank (2), 2016). According to Asian Development Bank (2016), Myanmar growth is forecast to accelerate during 2016 on recovery in agriculture and increase in foreign direct investment. Economic growth of Myanmar is projected to rise to 7.8 percent

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Why political violence and violent threats are on the rise in the United States

Ali Rogin Ali Rogin

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• Copy URL https://www.pbs.org/newshour/show/why-political-violence-and-violent-threats-are-on-the-rise-in-the-united-states

Studies show that over the past decade, there has been a steady increase in political violence and threats against public officials, like Saturday’s attempted assassination of Trump. Cynthia Miller-Idriss, director of American University’s Polarization and Extremism Research and Innovation Lab, joins Ali Rogin to discuss how we got to this point.

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Notice: Transcripts are machine and human generated and lightly edited for accuracy. They may contain errors.

Studies show that over the past decade, there's been a steady increase in threats against public officials and in political violence like yesterday's assassination attempt. Ali Rogin takes a closer look at how we got to this point.

Those instances of political violence also include attacks on local politicians, members of Congress and their spouses and political disagreements that turned deadly.

Cynthia Miller-Idriss is the director of research at American University's Polarization and Extremism Research Innovation Lab.

Cynthia, thank you so much for being here. This was a shocking event in a horrible tragedy for many Americans the first time that they've witnessed the attempted assassination of somebody who served as president. But of course, there have been many other acts of political violence in recent memory, including the attack on Nancy Pelosi's husband, Paul, in 2022. There was the congressional baseball practice shooting that injured Congressman Steve Scalise and 2017 plus many other attacks against local officials. Why are we experiencing this uptick in political violence?

Cynthia Miller-Idriss, Director, Polarization and Extremism Research Innovation Lab: Well, first, I have to say it should be condemned. Of course, we have to condemn the attack on former President Trump. You know, one of my earliest political memories was the assassination attempt on President Reagan. I think we are back in an era in which political assassinations are becoming a tactic again of in which people seek a solution to what they think are their political problems.

And that's part of the rising violence that we're seeing across the board politically, and also part of the rhetoric that has been increasing on polarized lines that positions us versus them and existential terms, so that the other starts to seem like a threat that has to be eradicated. So it's a problem at the elite level, and it's a problem among ordinary conversations as well.

And you mentioned the rhetoric, members of both parties have been coming out saying that both sides need to tone this down. How much of that is at issue here?

Cynthia Miller-Idriss:

The issue of political rhetoric that's divisive and even violent among elites is a huge problem. And it has been a huge problem for many years on both sides. However, I'm actually just as concerned about what I'm hearing from people I know and love even seeing on social media, things like you reap what you sow in response to this event. That's just as problematic.

You have a lone actor who is not only motivated by elites who mess up, but also by ordinary citizens who give up and who lean into the idea that violence is a solution to any kind of political ideas or problems.

One of NewsHour polls found earlier this year that one in five respondents believe Americans may have to resort to violence to get their own country back on track. That seems like a high number. What's your take?

It seems high, but it's accurate. I mean, that's exactly the kind of data that we've been seeing. We're seeing increasing support for political violence and also increasing willingness to engage in it among ordinary Americans. And that's what I mean about everybody seeing this as a moment of reckoning for themselves and their own behavior, not just to wag fingers at the elites, and politicians who are behaving badly.

But to think about what you do across the dining room table, what you're doing in your classrooms, what you're doing with your colleagues and your neighbors. Because anytime you're justifying that kind of violence, you never know who's going to overhear that, or how that contributes to the overall climate in which violence is seen as a solution.

And to that end, do you think that everybody has a role here in lowering the overall temperature that's got us to this very tense point?

Absolutely. I think everyone has not just a role, but an obligation to lower the temperature to see our basic humanity to see that no one deserves to be shot, no matter how much you disagree with what they say politically. And to also take steps to kind of curb things like misinformation, stop retweeting it, I mean to be critical consumers, and good citizens about what you share. I think that's one of the big takeaways here is that people have a role to play and an obligation to do it.

And in terms of response to this, this particular event, what are you concerned about happening in terms of people perpetrating potential violent responses?

Another thing that ordinary people can do is to be a little bit vigilant in the coming weeks and months, because unfortunately, an event like this does create the risk that you have both kind of militant groups who see now that they may have to step up, they think and protect this candidate, as we've seen in the past, and you also see the risk of reprisal attacks.

And so, this is a real moment for people to pay attention to be vigilant, if you hear someone you know, saying something, tone it down, you know, try to correct their statements and their behaviors and steer them away from the idea that violence is a solution to anything.

Cynthia Miller-Idriss, Director of Research at American University's Polarization and Extremism Research Innovation Lab. Thank you so much for being here.

Thanks for having me.

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Ali Rogin is a correspondent for the PBS News Hour and PBS News Weekend, reporting on a number of topics including foreign affairs, health care and arts and culture. She received a Peabody Award in 2021 for her work on News Hour’s series on the COVID-19 pandemic’s effect worldwide. Rogin is also the recipient of two Edward R. Murrow Awards from the Radio Television Digital News Association and has been a part of several teams nominated for an Emmy, including for her work covering the fall of ISIS in 2020, the Las Vegas mass shooting in 2017, the inauguration of President Barack Obama in 2014, and the 2010 midterm elections.

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• Systematic review
• Open access
• Published: 17 July 2024

Adaptability, Scalability and Sustainability (ASaS) of complex health interventions: a systematic review of theories, models and frameworks

• Lixin Sun   ORCID: orcid.org/0009-0004-8328-5845 1 ,
• Andrew Booth 1 &
• Katie Sworn 1  

Implementation Science volume  19 , Article number:  52 ( 2024 ) Cite this article

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Complex health interventions (CHIs) are increasingly used in public health, clinical research and education to reduce the burden of disease worldwide. Numerous theories, models and frameworks (TMFs) have been developed to support implementation of CHIs.

This systematic review aims to identify and critique theoretical frameworks concerned with three features of implementation; adaptability, scalability and sustainability (ASaS). By dismantling the constituent theories, analysing their component concepts and then exploring factors that influence each theory the review team hopes to offer an enhanced understanding of considerations when implementing CHIs.

This review searched PubMed MEDLINE, CINAHL, Web of Science, and Google Scholar for research investigating the TMFs of complex health interventions. Narrative synthesis was employed to examine factors that may influence the adaptability, scalability and sustainability of complex health interventions.

A total of 9763 studies were retrieved from the five databases (PubMed, MEDLINE, CINAHL, Web of Science, and Google Scholar). Following removal of duplicates and application of the eligibility criteria, 35 papers were eligible for inclusion. Influencing factors can be grouped within outer context (socio-political context; leadership funding, inter-organisational networks), inner context; (client advocacy; organisational characteristics), intervention characteristics (supervision, monitoring and evaluation), and bridging factors (individual adopter or provider characteristics).

This review confirms that identified TMFS do not typically include the three components of adaptability, scalability, and sustainability. Current approaches focus on high income countries or generic “whole world” approaches with few frameworks specific to low- and middle-income countries. The review offers a starting point for further exploration of adaptability, scalability and sustainability, within a low- and middle-income context.

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Contributions to the literature

This study identified that current existing theories, models and frameworks (TMFs) focus on high income countries or generic “whole world” approaches with few frameworks specific to low- and middle-income countries.

This study explored the factors influencing the adaptability, scalability and sustainability of complex health interventions within current TMFs.

This study evaluated the applicability and feasibility of current TMF in low- and middle-income countries.

Introduction

This systematic review examines the adaptability, scalability, and sustainability (ASaS) of complex health interventions (CHIs), which are increasingly used in public health, clinical research, and education to alleviate global disease burdens [ 1 ]. The effectiveness of CHIs depends on various factors, including health resources, education levels, and economic status [ 2 , 3 ].

CHIs are interventions with multiple interacting components, posing unique evaluation challenges beyond the usual practical and methodological difficulties [ 4 ].

Adaptability, scalability, and sustainability are crucial concepts in implementing CHIs, addressed through stages of evidence efficacy, scaling-up, and long-term sustainability [ 5 ]. Initial research phases focus on adapting interventions to local contexts and needs [ 6 ]. Once effectiveness is proven, the goal shifts to broader implementation, aiming for sustainability in real-world settings [ 5 ].The definitions of the ASaS is shown in the Table 1 .

Theories, models and frameworks are used extensively to advance implementation science [ 10 , 11 , 12 , 13 ], to guide the design and implementation of complex interventions, and to help in assessing their quality. The resultant models can also be used to elucidate causal mechanisms between influencing factors and to identify contextual factors associated with changes in outcomes [ 10 , 11 , 14 ]. In turn, TMFs offer a lens for the exploration of the complex fields of public health, health policy and social care [ 10 , 13 ].

Generally, a theory is:

“a set of inter‐related concepts, definitions and propositions that present a systematic view of events or situations by specifying relations among variables, to explain and predict the events or situations [ 15 , 16 ].

Simply put, theories, are closely related to models. Specially, theories are characterized as combining the explanatory alongside the descriptive, and models are defined as theories with a narrowly defined scope of explanation [ 16 ]. A framework is:

“a structure, overview, outline, system or plan consisting of various descriptive categories including concepts, constructs or variables, and the relations between them that are presumed to account for a phenomenon” [ 16 , 17 ].

Compared with theories and models, frameworks do not seek to be explanatory; rather than describe the internal relationships of concepts, they simply present the concepts [ 16 ]. However, despite some diverse characteristics, the terms “theory”, “model” and “framework” (TMF) are often used interchangeably.

However, most existing frameworks and measures for determining implementation factors and outcomes have originated in high-income nations [ 18 ]. A study indicated that although the number of frameworks related to program sustainability is increasing, these frameworks are rarely applied and evaluated in low- and middle-income countries or vulnerable communities within high-income countries. The primary reason for this phenomenon is the unique challenges faced by these countries and regions in terms of community and workplace capacities [ 19 ]. Therefore, it cannot be assumed that current TMFs are suitable for resource-limited settings [ 20 ].

Consequently, the aim of this review is to conduct a systematic review of theoretical frameworks concerned with at least one of the three ASaS concepts, to deconstruct the constituent theories, and to analyze the influencing factors within these frameworks. Another aim of this study is to assess the applicability and feasibility of these TMFs in diverse settings.

Specifically, the objectives of this review are:

To explore definitions of scalability, adaptability, and sustainability.

To identify published theoretical studies concerned with at least one of the concepts of sustainability, scalability and adaptability of complex health intervention-related frameworks and to assemble and explore relevant models and frameworks;

To explore inter-relationships between factors influencing scalability, adaptability, and sustainability of the complex health interventions;

To analyse the applicability and feasibility of these TMFs;

To appraise the methodological quality and reporting quality of the included literature.

Search strategy

Systematic review methods were employed to identify and select TMFs. Specifically, the BeHEMoTh procedure was used as a systematic approach by which to collect theoretical frameworks [ 10 ]. The BeHEMoTh procedure offers auditability and transparency when identifying published TMFs [ 21 ]. Specific features of the BeHEMoTh search process are outlined in Additional file 1. The search begins with a structured BeHEMoTh question. First, the researcher reviewed TMFs identified from a scoping review in order to construct a systematic search procedure for retrieving ASaS related TMFs via Google Scholar [Step 1a]. PubMed MEDLINE, CINAHL and Web of Science, were systematically searched using the same search strategy, in a process similar to a conventional systematic review search [step 1b]. Titles and abstracts were screened for TMFs using a spreadsheet with each additional instance being added to the list of TMFs previously identified via step 1 [step 2]. Named models retrieved from step 2, together with models found from scoping via Google Scholar, were then searched to retrieve additional related reports [step 3]. Searching of source references for these TMFs was used to reveal cited studies [step 4a and step 4b].

Search terms

Search terms across all sources were organized within five search term groups including the three ASaS concepts (See Additional file 1). By searching for the three ASaS concepts individually rather than for their intersect, the search strategy recognises that few models involve all three factors of ASaS with many involving one or two factors.

Inclusion and exclusion criteria

Identified publications were imported to Endnote 9 software and duplicates were deleted. Specific inclusion criteria for factors that influence ASaS of CHIs are shown in Table 2 .

Data extraction and appraisal

The titles and abstracts were screened, and the full papers of potentially relevant studies were obtained. Two authors independently assessed 10% of all titles and abstracts with a single reviewer then selecting full text papers for eligibility. An initial data extraction form was modified and adopted after revision. A single researcher independently extracted: (1) Study identification: year of publication, authors, name of study and name of the theories, models and frameworks; (2) Methods: study design, and study context; (3) any TMFs used; (4) Purpose of the theories, models, and framework; (5) Theories, models, and frameworks: definition, conceptual model, framework; (6) factors influencing ASaS of CHIs and inter-relationships between these concepts. These tables are shown in Additional file 3.

Quality assessment

Quality assessment criteria for assessing reports of TMFs are not common. Three papers were identified that either develop or utilize criteria for assessing theories [ 22 , 23 , 24 ] and these papers were used to compile the following quality assessment criteria:

Is the methodology identified and justified?

Was a theoretical lens or perspective used to guide the study, with a reference provided?

Is the theoretical framework described?

Is the theoretical framework easily linked with the problem?

If a conceptual framework is used, are the concepts adequately defined?

Are the relationships among concepts clearly identified?

Are the influencing factors of concepts clearly identified?

Are the relationships among influencing factors clearly described?

Quality assessments were undertaken by a single reviewer, quality assessment judgements are reported in Additional file 4.

Given that the literature relating to TMFs derives from multiple disciplines, the researcher decided to use a narrative synthesis approach, which allows for synthesis of diverse types, designs and contexts for studies [ 25 , 26 , 27 ].

First, collected TMFs were categorized against a pre-existing classification: (1) Process models; (2) Determinant frameworks; (3) Classic theories; (4) Implementation theories; (5) Evaluation frameworks [ 16 ] (Table 3 ).

To effectively analyze the factors influencing the adaptability, scalability, and sustainability (ASaS) of complex health interventions (CHIs), this review integrates insights from multiple frameworks. Initially, the EPIS (Exploration, Preparation, Implementation, Sustainment) model was utilized, categorizing influencing factors into four key dimensions: Outer Context, Inner Context, Intervention Characteristics, and Bridging Factors. However, a more comprehensive understanding was needed, as the EPIS model alone did not fully capture the complexity of these factors.

To address this, features from the CFIR (Consolidated Framework for Implementation Research) and insights from the NASSS (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability) framework and the Dynamic Sustainability Framework (DSF) were integrated. This meta-model enhancement involves expanding the descriptions within each EPIS dimension to cover additional critical elements found in these other frameworks.

Specifically, within the Inner Context, the organizational characteristics were elaborated to reflect deeper organizational dynamics affecting CHIs. In the Outer Context, the Sociopolitical Context was added, acknowledging its crucial influence on intervention outcomes. Further, the Intervention Characteristics were detailed more extensively to capture the nuanced nature of the interventions themselves.

This enriched model aims to provide a robust analytical framework that better reflects the complex interplay of factors influencing the ASaS of CHIs. By adopting this meta-model, the study offers a comprehensive theoretical foundation that underpins the examination of these complex interventions, paving the way for more targeted and effective implementation strategies in diverse settings.

Finally, the Theoretical Quality Tool, adapted from Hean et al. [ 31 ], was employed to rigorously assess the applicability of the collected (TMFs) in the context of Low- and Middle-Income Countries (LMICs).

Characteristics of included studies

The flowchart of the search results (Fig. 1 ) shows that the search identified 9763 studies. Following removal of duplicates and application of eligibility criteria, 37 studies remained for inclusion in the review. 25 studies provide macroscopic TMFs for CHIs [ 5 , 6 , 7 , 8 , 9 , 30 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] worldwide. A further seven included TMFs [ 50 , 51 , 52 , 53 , 54 , 55 , 56 ] that were developed in high-income countries and only five studies [ 21 , 57 , 58 , 59 , 60 ] targeted LMICs.

PRIMA diagram of article selection

Types of TMF

Overall, 28 [ 5 , 6 , 7 , 8 , 9 , 21 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 49 , 50 , 55 , 57 , 58 , 61 ] of the 37 studies describe macroscopic TMFs and nine studies [ 30 , 47 , 51 , 52 , 53 , 54 , 56 , 59 , 60 ] describe TMFs for specific relevant interventions. Categorising these according to the five categories of Per Nilsen's schema (Table 3 ) reveals that 14 of the 37 TMFs are process models, 14 are determinant frameworks, one is classic theory, one is implementation theory, and seven are evaluation frameworks (See Additional file 5). One classic theory and one implementation theory are included. The Detailed classification for collected TMFs is described in Table 4 .

Adaptability, scalability and sustainability definitions

All 37 included studies reported at least two out of the three concepts of ASaS, and the specific concepts involved in each study. (See Table 5 ). Definitions of ASaS found in the included studies are shown in the Additional file 2.

The process of implementation and relationships of adaptability, scalability and sustainability

Diverse TMFs support a strong correlation between the three ASaS concepts and the implementation process. Twenty-five of the TMFs explicitly mentioned implementation of CHIs; while the remaining ten did not [ 6 , 8 , 21 , 39 , 40 , 44 , 54 , 55 , 56 , 62 ].

This review confirms the interconnectedness of adaptability, scalability, and sustainability in the implementation of complex health interventions (CHIs). The findings suggest that adaptability is crucial during the initial stages of CHI deployment, determining the potential for effective and cost-efficient implementation. As the intervention progresses, scalability becomes critical, ensuring that strategies effective on a smaller scale can be expanded to broader populations and regions. Ultimately, sustainability is achieved in the final stages, focusing on maintaining the benefits of the intervention over time and making necessary adjustments based on ongoing feedback and changing conditions.

In essence, the successful scaling and long-term sustainability of CHIs fundamentally depend on their initial adaptability. This streamlined approach highlights the critical progression from adaptability through scalability to sustainability, without delving into the specifics of various models and frameworks.

Influencing factors of adaptability, scalability and sustainability of complex interventions

This study collected and analyzed factors affecting the adaptability, scalability, and sustainability (ASaS) of complex health interventions (CHIs), systematically categorizing them into four distinct categories: outer context, inner context, intervention characteristics, and bridging factors. This classification helps clarify the various factors that influence the implementation of health interventions.

While all these factors impact the three concepts of ASaS, some have particularly close relationships with specific ASaS concepts. Subsequent sections will explore these factors in detail, emphasizing those closely linked to individual ASaS concepts. This approach highlights the multidimensionality of these factors and their varying impacts on the adaptability, scalability, and sustainability of CHIs. The overview of the factors influencing the ASaS is shown in the Table 6 .

Outer context

Name of influencing factors, suggested definition, frequency of influencing factors of Outer context is shown in Table 7 .

Sociopolitical context

This study has identified multiple studies highlighting how sociopolitical factors deeply influence the adaptability, scalability, and sustainability (ASaS) of complex health interventions (CHIs) [ 8 , 30 , 35 , 37 , 39 , 42 , 44 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 58 , 59 , 60 , 64 ]. These factors, including religion [ 58 ], ethics [ 39 , 56 ], legislation [ 30 , 35 , 39 , 44 , 54 , 58 , 59 , 64 ], norms or regulations [ 7 , 21 , 35 , 38 , 49 , 54 , 56 , 58 ], and policies [ 6 , 7 , 9 , 21 , 35 , 37 , 38 , 39 , 44 , 50 , 51 , 54 , 56 , 57 , 59 ], play a critical role in shaping health outcomes and addressing healthcare disparities. The influence of sociocultural factors such as common traditions, habits, patterns, and beliefs was also evident across different populations [ 35 , 37 , 38 , 39 , 44 , 50 , 52 , 54 , 57 , 58 , 62 ].

Interorganizational networks

Interorganizational networks bridge full-scale relationships across organizations [ 65 ], and it was found to significantly enhance the implementation of CHIs, enabling better adaptation to local contexts and sustainability at lower costs through effective resource sharing and communication.

Also, the role of funding was another major factor discussed, highlighting its critical importance for providing necessary resources such as training, materials, and health services [ 66 ]. Nineteen of the identified models or frameworks emphasize fiscal support prioritized in implementation [ 6 , 7 , 8 , 9 , 21 , 30 , 34 , 35 , 36 , 38 , 39 , 44 , 45 , 50 , 54 , 55 , 58 , 59 , 64 ].

Client advocacy

Three of the 37 studies identify client advocacy as an important influencing factor [ 9 , 45 , 50 ]. During implementation client advocacy assists healthcare workers, participants and their families in navigating the healthcare system [ 67 ].

Finally, 16 of the 37 studies emphasize leadership [ 6 , 21 , 30 , 35 , 36 , 40 , 42 , 43 , 44 , 45 , 50 , 51 , 56 , 57 , 58 , 59 ]. Specific subgroups may offer either approval or conflict. Strong leadership can promote effective use of resources while encouraging personnel to work towards a common goal.

Inner context

Name of influencing factors, suggested definition, frequency of influencing factors of Outer context is shown in the Table 8 .

Organizational characteristics

Organizational characteristics influence the process of implementing complex health interventions (CHIs) through structures and processes within organizations. These characteristics encompass ten influencing factors including absorptive capacity [ 6 , 8 , 9 , 21 , 36 , 37 , 40 , 44 , 50 , 51 , 52 , 56 , 57 , 59 , 64 ], organizational readiness [ 8 , 30 , 50 , 51 , 52 ], structure [ 6 , 7 , 35 , 38 , 40 , 44 , 49 , 51 , 52 , 59 , 64 ], values or visions [ 35 , 37 , 40 , 43 , 44 , 51 , 59 ], working environment [ 6 , 7 , 8 , 9 , 41 , 45 , 50 , 51 , 54 , 56 ], tension for change [ 6 , 49 , 51 , 53 ], organization culture [ 6 , 35 , 40 , 43 , 50 , 58 ], leadership [ 6 , 21 , 35 , 36 , 40 , 42 , 43 , 44 , 45 , 50 , 51 , 56 , 57 , 58 , 59 ], credibility and reputation [ 43 ]. The adaptability, scalability, and sustainability (ASaS) of CHIs are significantly dependent on these organizational elements.

Organisations with strong organisational power may be likely to implement CHIs because they have stronger leadership and more frequent communication than those with weak or decentralised organisational structures [ 68 ].

Readiness for change

In addition, strong organisations are prepared and aware of possible encountered changes and can adjust their strategies and approaches of working in time to enable CHIs to be carried out well. Readiness for change is related to other factors including organisational culture, and individual attitudes [ 69 , 70 , 71 , 72 ].

Absorptive capacity

During the exploration and preparation phases of a CHI, an organisation's absorptive capacity (the ability to identify, assimilate, transform, and use external knowledge, research and practice [ 73 ]), readiness for change and receptive environment exert a significant impact on the adaptability of CHIs.

Individual adopter or provider characteristics

Individual adopter or provider characteristics include participants’ personal characteristics, age, race/ethnicity, education, training, foundation subjects, professional experience, adaptability, personal values and goals, and personal character creative ability.

Fourteen included studies emphasise how the CHI is accepted and scaled-up by participants and health care workers [ 6 , 7 , 8 , 34 , 35 , 36 , 41 , 45 , 47 , 51 , 53 , 54 , 56 , 58 ]. In parallel to the organisational level, individual ability or capacity [ 6 , 35 , 44 , 51 , 53 , 56 , 57 , 64 ], training or education [ 7 , 8 , 35 , 36 , 40 , 51 , 52 , 56 ], and tenacity for change [ 6 , 51 , 53 ] constitute important factors. CHIs are more easily adapted and diffused when led by experienced and leaders [ 6 , 21 , 35 , 36 , 40 , 42 , 43 , 44 , 45 , 50 , 51 , 56 , 57 , 58 , 59 ] with common visions or views [ 6 , 35 , 51 , 53 , 56 , 60 , 64 ]. In addition, race [ 35 , 50 ], spoken language [ 35 , 50 , 52 ] and individual culture [ 35 , 53 , 56 , 59 ] are considered to be vital influencing factors. Specifically, when there is a high degree of fit between the norms and values of the individual, organisation and CHIs, individuals may find that they achieve higher efficacy when implementing CHIs [ 64 ].

As mentioned above, 16 of the 37 included studies emphasize leadership [ 6 , 21 , 30 , 35 , 36 , 40 , 42 , 43 , 44 , 45 , 48 , 50 , 51 , 56 , 57 , 58 , 59 ].

CHIs require sufficient, well-trained healthcare workers. Fourteen of the 37 studies list staffing as an important factor in their TMFs [ 7 , 30 , 34 , 35 , 36 , 37 , 43 , 44 , 45 , 50 , 51 , 52 , 56 , 64 ]. Job candidates may be selected so that their knowledge, skills, competencies, and attitudes [ 74 ] match the requirements of the CHI.

Supervision, monitoring and evaluation

Supervision, monitoring and evaluation refers to the collection, storage, analysis and use of data to assess whether complex interventions are achieving their intended objectives, and further influences improvement, policy development and advocacy of complex intervention [ 75 ]. Nine of the 35 studies argue for the vital role of monitoring and evaluation in providing an effective approach by which to assess the effectiveness of complex interventions [ 21 , 30 , 40 , 43 , 44 , 50 , 51 , 58 , 64 ].

Intervention characteristics

The characteristics of the intervention itself is also an important factor. Specifically, the physical and community environment, the cost of the intervention and access to resources (8 studies) [ 6 , 21 , 30 , 34 , 38 , 51 , 52 , 56 ] and the source of funding all exert a direct impact. Project champions are committed to supporting and promoting the implementation of CHI, along with a strong belief in the value of carrying out CHIs [ 76 ]. The factors within intervention characteristics is shown in the Table 9 .

The included frameworks attest to how the characteristics of the CHI decide whether an intervention can be adapted, scaled-up and sustained [ 6 , 8 , 33 , 36 , 47 , 51 , 53 ]. Although researchers hope that CHIs can be adapted and conducted as quickly as possible, it takes time for both healthcare providers and participants to adapt to new interventions [ 77 ]. Also, when interventions change significantly within a short period of time, the lack of sufficient time to adapt to the intervention and adjust to relevant cultural factors prevent staff and participants from adopting a new CHI [ 78 ].

Bridging factors

Factors influencing the inter-relationship of outer and inner context are described as “bridging factors” in the EPIS framework. Bridging factors include community engagement and Purveyors/Intermediaries.

Twelve studies stress the importance of the community. Development of complex interventions within a community may be facilitated when they utilise existing community resources, available structures and staff, reducing dependence on external funding [ 21 ]. For example, community members were proud to participate in a project to improve malaria prevention through insecticide-treated mosquito nets and thereby contribute to disease control within their community. Consequently, the project was speedily adapted, replicated and scaled-up locally [ 79 ]. The community function is also affected by socio-political factors [ 80 ]. If the visions and beliefs of the policy are inconsistent with community objectives, the policy hinders spread and sustainability even where the community possesses powerful leadership, project champions and sufficient resources [ 80 , 81 ].

Purveyors/Intermediaries take on a critical bridging role for key processes in the implementation of CHIs [ 45 ]. Purveyors, who may be individuals, groups or communities, aim to facilitate the effective and sustainable implementation of CHIs [ 82 ]. Intermediaries provide consultancy and training services to governments, organisations, etc., and also develop and implement different health-services and projects for them [ 82 ]. They also provide monitoring, support, quality improvement and evaluation services at the end of the project [ 82 ]. The factors within bridging factors is shown in the Table 10 .

Applicability and feasibility of the collected TMFs

This study employs the Theoretical Quality Tool, adapted from Hean et al. [ 31 ], to rigorously assess the applicability of various Theoretical Models and Frameworks (TMFs) in the context of Low- and Middle-Income Countries (LMICs). The detailed outcomes of this assessment are presented in the Additional file 6. The summary table highlights the applicability and feasibility of TMFs in LMICs.

Of the 37 TMFs reviewed (two studies identify EPIS), seven demonstrate high applicability and feasibility, readily integrating into LMIC healthcare environments without necessitating significant overhauls. For example, models like the AIDED and NPT are readily implementable in LMICs due to their practicality and context-sensitive design. They integrate seamlessly into existing healthcare systems, offering solutions without the need for extensive system overhauls, crucial in resource-limited environments. Twenty-five TMFs require adaptations to align with the local conditions of LMICs, entailing modifications to fit cultural, economic, and healthcare infrastructure nuances. For example, the EPIS framework, CFIR framework, PRISM Model and Chronic Care Model, though broadly applicable, need customization to fit the unique cultural, economic, and healthcare infrastructures of LMICs.

For the remaining five TMFs, their inherent theoretical complexity and the fact that some were specifically designed for High-Income Countries (HICs) pose significant barriers to adoption in in Low- and Middle-Income Countries (LMICs). This finding highlights an important disconnect between their foundational assumptions and the practical realities of healthcare systems in LMICs. The evaluation outcomes of the applicability and feasibility of the collected 37 TMFs are shown in the Table 11 .

This theoretical systematic review identified common features and differences across 37 TMFs associated with ASaS.

Similarities and differences between the TMFs

All identified TMFs emphasize the importance of one or more of the three ASaS concepts. These frameworks aim to enable CHIs to adapt to new contexts and populations, scale up interventions, and ensure long-term effectiveness. The components of different TMFs share broadly similar descriptions, even if the terminology varies. For example, the EPIS framework divides the implementation process into four phases: exploration, preparation, implementation, and sustainment whereas Sarma’s framework [ 5 ] describes three domains: i: evidence – efficacy to effectiveness; ii: Scaling-up; and iii: sustainability. A further study [ 36 ] describes four stages 1. Training (dissemination); 2. adoption (planning); 3. implementation; 4. practical improvement and two key points (preparation and maintenance).

In the EPIS framework, during exploration and preparation, adaptability is considered to determine whether the complex intervention can be conducted effectively with affordable cost. Domain I of Sarma’s framework [ 5 ] includes the four vital components of intervention sources, evidence strength and quality, relative advantages, adaptability and complexity. The Framework - oral health [ 36 ] emphasizes adoption within the second stage. Hence, these three stages have the similar key components. The EPIS framework describes how a pilot study is further implemented across diverse participants and areas, which is similar to Domain ii: Scaling-up in Sarma’s framework [ 5 ] and the implementation stage in Framework - oral health [ 36 ]. Finally, the sustainment stage in EPIS framework, Domain iii: sustainability in Sarma’s framework [ 5 ] and the maintenance point in Framework - oral health [ 36 ] all convey a shared understanding of sustainability.

Similar stages may be presented in a different order within various models, reflecting the inherently multi-stage and non-linear nature of CHI implementation. Significant differences across different TMFs primarily relate to influences on ASaS. Furthermore, even when different TMFs use the same terminology to describe influencing factors, the meanings may differ due to the inherent complexity and dynamics of these factors.

The complexity of influencing factors of adaptability, scalability and sustainability

The TMFs reflect how CHIs and associated influencing factors do not operate in isolation, but are non-linear, interacting and interdependent. Some influencing factors appear across multiple studies. For example, researchers share a consensus about the importance of funding [ 6 , 7 , 8 , 9 , 21 , 34 , 35 , 36 , 38 , 39 , 44 , 45 , 50 , 54 , 55 , 58 , 64 ]. Some studies emphasise adequate and sustained financial support from governments and foundations as prerequisite to the sustainability and spread [ 5 , 44 , 50 , 61 ], while Sarma [ 5 ] recognizes the need to sustain interventions in the absence of adequate funding [ 21 ]. In addition, the sociopolitical context, leadership and organizational characteristics are repeatedly mentioned as essential components for implementation. Furthermore, all the factors mentioned in the literature are bi-directional; the same influencing factor may act differently under diverse conditions, either as a facilitator or as a hindrance.

To be specific, first, in terms of the outer context, strong leadership can facilitate effective use of resources while encouraging personnel to work towards a common goal. Also, sociopolitical factors covers ethical considerations [ 39 , 56 ], legislation [ 35 , 39 , 44 , 54 , 58 , 64 ], norms or regulations [ 7 , 21 , 35 , 38 , 54 , 56 , 58 ], policies [ 6 , 7 , 9 , 21 , 35 , 37 , 38 , 39 , 44 , 50 , 51 , 54 , 56 , 57 ], and religion [ 58 ]. Legislation and policies not only guide, and often guarantee, complex interventions at the macro level, but also, at the empirical level, provide a basis for adapting CHIs to the local environment thereby making interventions suitable for scale up and long term sustainment [ 35 , 39 , 44 , 54 , 58 , 64 ]. High quality interorganizational communication contributes to the implementation and sustainability of CHIs [ 83 ]. Additionally, weak leadership exerts a negative impact on the management of the organisation, funding applications and the recruitment of staff.

Leadership remains an important factor in relation to the inner context. Given that complex interventions are often run by the state, an organisation or a group, strong leadership can facilitate complex interventions. Also, the organisational culture, the vision/belief and the structure of the organisation interact with each factor and are influenced by funding, leadership and staffing.

Strong leadership needs to be accompanied by a structured organisation with a common vision in order to achieve the objectives of complex interventions. People as the carriers of culture, organisation, professional and personal attitudes, norms, interests and affiliations [ 84 ] also fulfil an important role. Individual adopter or provider characteristics are important influencing factors. When people within the organisation are aligned with the organisation's philosophy and culture, along with sufficient financial support, strong leadership and effective supervision, adaptation, scale up and long-term sustainment become possible for CHIs. Finally, intervention factors are influenced by both the outer context and the inner context, and bridging factors serve to unite the outer context, the inner context, and the intervention factors.

The dynamics of influencing factors of adaptability, scalability and sustainability

Factors that influence complex interventions are dynamic in both temporal and geographical terms. The role of these factors may change over time [ 85 ]; anticipated barriers may become facilitators [ 85 ]. For example, in the early stages of an intervention, individual adopters may exhibit skepticism and distrust, presenting a barrier to CHI delivery. However, in later stages, if the intervention proves effective, participant attitudes may shift, motivating them to cooperate and thus becoming facilitators. Similarly, in the early stages, newly recruited or local staff may be unfamiliar with the intervention, posing a hindrance. Conversely, as staff become familiar with the intervention, they are better equipped to implement it, thereby becoming facilitators.

Identical influencing factors may have different effects in various geographical and national contexts. For example, women are generally considered a vulnerable group worldwide, particularly in LMICs, where they tend to have lower income and social status compared to men, making it difficult for them to access better health care resources [ 86 ]. However, in the matrilineal community in Indonesia, women occupy similar or even higher social status than men, with a cultural tradition of controlling family finances [ 87 ]. Therefore, in this context, gender and culture may facilitate interventions, especially maternal and child health related interventions. In relation to funding, reliable sources of funding help to sustain interventions [ 5 ], and one of the challenges to sustainability is the lack of long-term available funding [ 21 ]. In summary, this systematic review offers a comprehensive understanding of factors influencing ASaS and provides a theoretical framework for effective CHIs in the future.

Have gaps in knowledge been addressed?

This is the first systematic review of ASaS related TMFs of CHIs. By focusing on the three factors of adaptability, sustainability and spread the review has been able to explore complex interactions of each with each other and with other important factors.

How have authors defined scalability, adaptability, and sustainability?

Additional file 2 consolidates definitions of scalability, adaptability and sustainability as identified across the included studies. It is noticeable that “sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase’ that integrates and institutionalizes interventions within local organizational and cultural contexts.” [ 7 ]

This literature argues that sustainability is, in fact, a manifestation of adaptability, and that the two concepts are closely related.

Which theoretical studies explore at least one of the concepts of scalability, adaptability and sustainability of complex health intervention within a relevant model/frameworks;?

This review reveals the scarcity of theoretical models for LMICs. The review identified four main categories of theoretical models, (i) the generic TMFs (e.g. RE-AIM and CFIR), with no obvious geographical target (26/37); (ii) tailored TMFs developed by some high-income countries (e,g. [ 52 , 53 , 56 ]. for local needs (6/37); (iii) adapted TMFs (e.g. EPIS and Framework of Dissemination in Health Services Intervention Research), originally designed for high-income countries but now adapted to CHIs worldwide; (iv) TMFs specific to low and middle income countries (5/37) (e.g. [ 21 , 57 ]). 85.7% of the included theories are either generic or specific to high-income countries, with a lack of TMFs specifically targeted at LMICs. As a result of this literature review the team have proceeded to develop a framework for Adaptability, Scalability and Sustainability that is suited for a low- and middle-income country context.

Thirty seven studies explore at least one of the concepts of sustainability, scalability and adaptability. However, no previous studies have explored all three ASaS concepts within a single TMF. Although some studies invoke the need to explore influencing factors and correlation among ASaS, no studies have actually conducted this research.

What inter-relationships have been demonstrated between factors influencing scalability, adaptability, and sustainability of the complex health interventions?

The meta-framework provides a comprehensive structure to explore the complexities of CHI implementation, emphasizing the interplay among four critical domains: outer context, inner context, intervention characteristics, and bridging factors.

In the outer context, the interplay between strong leadership, sociopolitical factors, and interorganizational networks is crucial. Strong leadership promotes resource optimization and strategic alignment toward CHI goals, essential for ASaS [ 35 , 39 , 44 , 54 , 58 , 64 ]. Sociopolitical factors, including legislation, policies, and norms, provide a regulatory framework that guides the adaptation of CHIs to local settings, enhancing their feasibility and long-term integration [ 83 ]. Additionally, robust interorganizational communication facilitates effective adaptation of CHIs to local contexts, potentially lowering costs and enhancing sustainability.

Within the inner context, organizational culture, structure, and leadership significantly interact, affecting CHI outcomes. Strong, visionary leadership is crucial for fostering an organizational culture that supports CHIs and aligns with broader intervention goals [ 84 ]. The organization's structure further influences the implementation of these interventions, with well-structured organizations likely to achieve better scalability and sustainability. Additionally, the characteristics of individual providers and adopters play a critical role, impacting their ability to effectively implement and sustain CHIs.

The characteristics of the intervention itself directly impact its implementation. Factors such as the intervention's complexity, cost, resource requirements, and specific design elements determine the ASaS especially for the stages of adaptability and scalability [ 6 , 21 , 30 , 34 , 38 , 51 , 52 , 56 , 59 ]. Support from project champions and stakeholder involvement are crucial in facilitating the implementation process, ensuring that the interventions are well-supported and aligned with stakeholder expectations [ 8 , 21 , 34 , 36 , 37 , 40 , 44 , 49 , 50 , 56 , 60 ].

Bridging factors like community engagement and the role of purveyors/intermediaries are vital for linking the outer and inner contexts of CHIs. Community engagement leverages local resources and capacities, which is essential for the localized adaptation and sustainability of interventions [ 8 , 9 , 21 , 30 , 34 , 38 , 42 , 44 , 45 , 54 , 56 , 58 ]. Purveyors and intermediaries facilitate the transfer of knowledge and best practices, enhancing the overall effectiveness and reach of CHIs [ 45 ]. These bridging roles ensure that interventions are not only well-integrated within communities but also maintain fidelity to their objectives and outcomes over time.

Lack of TMFs designed for LMICs

The lack of specifically designed TMFs for LMICs presents significant challenges in effectively implementing complex health interventions (CHIs) in these settings. Evaluating existing TMFs reveals a gap in their suitability and feasibility for application within the unique healthcare environments of LMICs.

Of the 37 TMFs assessed, many were found to require adaptations to align with the local conditions of LMICs, necessitating modifications to fit cultural, economic, and healthcare infrastructure nuances. For instance, frameworks such as EPIS, CFIR, PRISM Model, and Chronic Care Model, though broadly applicable, need customization to fit the unique contexts of LMICs.

Five of the TMFs reviewed were identified as inherently complex and primarily designed for high-income settings, posing substantial barriers to their adoption in LMICs. This highlights a critical disconnect between the foundational assumptions of these models and the practical realities of healthcare systems in LMICs, which face challenges such as limited resources, differing disease burdens, and varied healthcare delivery systems.

Despite these challenges, some models demonstrate higher applicability and feasibility. For example, the Dynamic Sustainability Framework (DSF) and the AIDED model are noted for their practicality and context-sensitive design, aligning with the continuous adaptation and learning required in LMICs. These models integrate seamlessly into existing healthcare systems, offering solutions without the need for extensive system overhauls, which is crucial in resource-limited environments.

The findings underscore the need to develop or adapt existing TMFs specifically tailored to the conditions of LMICs. This involves considering local healthcare practices, resource limitations, and cultural factors to ensure that the frameworks are both applicable and feasible in supporting the effective implementation and sustainability of CHIs in these settings.

Strengths and limitations

This systematic review retrieved relevant literature through a comprehensive search across four databases. Only studies published in English were included, potentially missing those from the grey literature. Identifying relevant implementation TMFs proved challenging due to the complex and diffuse terminologies used in this field. Exhaustive lists of synonyms would have been prohibitive, resulting in lack of specificity and numerous false positives. The authors sought an optimal balance between sensitivity and workload. Although the included studies were evaluated using a quality assessment tool, the risk of bias remains, particularly since only one author was responsible for data extraction.

Furthermore, although this review has identified how influencing factors interact, no clear theoretical model charts the specific TMFs, routes, and pathways from the influencing factors to the ASaS of CHIs. Finally, concepts such as acceptability, fidelity, and feasibility, are recognized as important features of CHIs [ 88 ] but fell outside the remit of this review.

Only one classic theory and one implementation theory are included. There are two possible reasons. Classical theories are borrowed from such disciplines as psychology, sociology and organisational development (e.g. the Diffusion of Innovation theory [ 89 ]. Similarly. the Health Belief Model was published in 1950 [ 90 ] and the Theory of Planned Behavior in the late 1980s [ 91 ]. Given that inclusion requires publication after 2000, many classic theories predate the study period. On the other hand, other theories, such as the implementation climate theory [ 92 ], may not be conceptually related to ASaS, resulting in their exclusion. The Detailed classification for collected TMFs is described in Table 4 .

This review synthesizes 37 TMFs that document factors influencing the ASaS of CHIs. It confirms the wide variety of definitions used for adaptability, scalability, and sustainability within current TMFs, which typically do not include all three components. Current approaches focus on high-income countries or generic “whole world” approaches, with few frameworks specific to low- and middle-income countries. Numerous attempts have been made to describe and explore the interrelationships between implementation components. Of these, the EPIS and CFIR frameworks seem to possess the greatest inherent value, particularly within a model consisting of outer context, inner context, intervention characteristics, and bridging factors. This review offers a starting point for further exploration of adaptability, scalability, and sustainability, particularly within a low- and middle-income context.

Availability of data and materials

All data cited in this review derives from published papers and therefore already available.

Abbreviations

Adaptability, scalability and sustainability

Capability, Opportunity, Motivation and Behaviour

• Complex health interventions

Evidence-based practice

Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Low- and middle- income countries

Medical Research Council

Theory, model and framework

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Acknowledgments

We gratefully acknowledge Prof. Andrew Booth and Dr. Katie Sworn their review of the manuscript and guidance on the systematic review process.

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LS conceived the research questions and prepared the research protocol in conjunction with AB and KS. LS designed the study, conducted the literature searches, and analyses. AB and KS refined the research question, contributed to the study design, participated in the literature review, helped prepare the first draft and revisions. All authors read and approved the final version of the manuscript for submission.

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Sun, L., Booth, A. & Sworn, K. Adaptability, Scalability and Sustainability (ASaS) of complex health interventions: a systematic review of theories, models and frameworks. Implementation Sci 19 , 52 (2024). https://doi.org/10.1186/s13012-024-01375-7

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Received : 18 January 2024

Accepted : 23 June 2024

Published : 17 July 2024

DOI : https://doi.org/10.1186/s13012-024-01375-7

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