ABSTRACT

Objective

To determine the impact that intersectoral policies and social participation, implemented worldwide, have had on the modification of the social determinants for health and on the reduction of social health inequities.

Method

A scoping review of the literature published in the period 2005-2015 was performed. The literature search was conducted on PubMed and Scielo databases. Two researchersreviewed each document. Data were analysed according to the intersectoral action and social participation variables and according to the theoretical frameworks of the Social Determinants Model of the Commission on Social Determinants of Health (CSDH) and the theoretical constructs of Social Capital (SC) and Life Course (LC).

Results

Out of 45 documents likely to be selected for final review, all of them based on title and abstract, 20 documents were eventually picked out and analysed; most them (n = 8) were conducted in all Latin America and Latin America's countries. Twelve documents reported intersectoral action associated with social participation in partnership with different institutions. Regarding theoretical frameworks, most of studies (n = 8) used CSDH and SC. In relation to health outcomes, the studies showed mainly: increased access to health and education, follow-up of pregnant women, increasing in prenatal examinations, reduction in malnutrition/child mortality, reduction in extreme poverty/hunger; reduction in epidemics/tuberculosis, control of alcohol/drug consumption, promotion of health/mental as well as basic sanitation improvements.

Conclusions

Intersectoral and social participation experiences studied yielded positive outcomes regarding health status and quality of life in the communities in which such experiences were implemented.

Keywords:
Intersectorality; Social participation; Social inequities; Social determinants of health; Policies

RESUMEN

Objetivo

Determinar el impacto que las políticas intersectoriales y la participación social, implementadas en todo el mundo, han tenido tanto en la modificación de los determinantes sociales de la salud como en la reducción de las desigualdades sociales en salud.

Método

Se realizó una revisión exploratoria (periodo 2005-2015). La búsqueda bibliográfica se hizo en las bases de datos PubMed y Scielo. Cada artículo fue revisado por dos investigadores. Los datos fueron analizados según las variables de acción intersectorial y participación social, y de acuerdo con los marcos teóricos: modelo de determinantes sociales de la Comisión de Determinantes Sociales de la Salud (CDSS) y constructos teóricos de capital social (CS) y curso de la vida.

Resultados

De los 45 documentos seleccionables para la revisión final, basándose en el título y el resumen, 20 fueron seleccionados y analizados; la mayoría (n = 8) realizados en América Latina. Doce artículos informaban sobre acciones intersectoriales en asociación con participación social en colaboración con diferentes instituciones. En cuanto a los marcos teóricos, la mayoría (n = 8) utilizaron CDSS y CS. En relación con los resultados de salud, los estudios mostraron principalmente: mayor acceso a la salud y educación, seguimiento de embarazadas, aumento en exámenes prenatales, reducción de la desnutrición/mortalidad infantil, reducción de la pobreza extrema/hambre, reducción de las epidemias/tuberculosis, control del consumo de alcohol/drogas, promoción de la salud/salud mental, y mejoras en el saneamiento básico.

Conclusiones

Las experiencias intersectoriales y de participación social estudiadas arrojan resultados positivos en el estado de salud y calidad de vida de las comunidades en que fueron implementadas.

Palabras clave:
Intersectorialidad; Participación social; Desigualdades sociales; Determinantes sociales de la salud; Políticas

Introduction

Around 10 years after the creation of the WHO Commission on Social Determinants of Health (CSDH-WHO), and after some progress in studies on reducing health inequities, particularly in Europe, high indices of vulnerability and social inequity continue in certain social groups. This situation produces differentiated access to material and symbolic resources that impact the health of people and populations.¹1. Stuart K, Soulsby EJL. Reducing global health inequalities Part 1 J R Soc Med. 2011;104:321-6.

In Latin American and other poor countries, there are peripheral urban territories marked by poverty, low education levels, unemployment or informal income generation, violence, insertion, high rates of abuse of alcohol and other drugs, disruption of social networks of support, and geographical and political exclusion. Africa has even the highest morbidityburden compared to other regions, and it also has the lowest per capita expenditure on health.¹1. Stuart K, Soulsby EJL. Reducing global health inequalities Part 1 J R Soc Med. 2011;104:321-6. Studies show how the poverty present in many people affects all life and health from birth and throughout the life course reducing life expectancy and increasing the chances of premature death in the most inequitable countries. Focusing on poverty is essential to Global Commission on the Social Determinants of Health.²2. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the CSDH. Geneva: World Health Organization; 2008. (Accessed 14/09/2016). Available at: http://www.who.int/social determinants/thecommission/finalreport/en
http://www.who.int/social determinants/t...

3. Chaves TV, Sanches GM, Ribeiro LA, et al. Fissura por crack: comportamentos e estratégias de controle de usuários e ex-usuários Revista de Saúde Pública. 2011;45:1168-75.

4. Barros A, Rosmans C, Axelson H, et al. Equity in maternal, newborn and child health intervention in Countdonw to 2015: a retrospective review of survey data from 54 countries Lancet. 2012;379:225-33.^-55. Goeij MCM, Suhrcke M, Toffolutti V, et al. How economic crises affect alcohol consumption and alcohol-related health problems: a realist systematic review Soc Sci Med. 2015;131:131-46. Exclusion from or difficult access to income, work, education, housing, transportation and mobility, culture, leisure, a sustainable environment and social support networks cause of health inequities in poor countries. There are groups of people that suffer health problems and deaths, which are unfair and avoidable.⁶6. Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global Annu Rev Publ Health. 2011;32:225-36. ⁷7. Sambo LG, Kirigia JM, Ki-Zerbo G. Health financing in Africa: overview of a dia- logue among high level policy makers BMC Proceedings. 2011;5(Suppl 5):S2.

Studies have emphasised the strong recommendation of the CSDH-WHO in the construction of intersectoral policies to address health inequities. Intersectoral Action for Health is an important component of the Global Strategy for Health for All by the Year 2000 and a component of the 2006 “Health in All Policies” (HiAP). A HiAP approach promotes “effective and systematic action for the improvement of population health, using genuinely all available measures in all policy fields”.⁸8. Ståhl T, Wismar M, Ollila E, et al., editors. Health in all policies: prospects and potentials. Finland: Ministry of Social Affairs and Health; 2006. p. 299. Intersectoral actions should occur at superstructural levels and be based on agreements between areas of government, i.e. all other sectors (economic, labour and employment, education, transportation, housing, environment, etc.) should elect health promotion as a priority, through global action aimed at reducing social inequities.⁹9. Moral PAP, Gascón MLG, Abad ML. La salud y sus determinantes sociales: desigualdades y exclusión en la sociedad del siglo XXI Rev Int Sociol. 2014;72 (Supl 1):71-91.

10. WHO. Social determinants of health. Report by the Secretariat, 132nd session. Geneva: WHO; 2012. (Accessed 14/09/2016). Available at: https://www.who.int/ .
https://www.who.int/...

11. Comisión para Reducir las Desigualdades Sociales en Salud en Espana. Propuesta de políticas para reducir las desigualdades en salud en Espana Gac Sanit. 2012;26:182-9.

12. Borrell C, Morrison J, Burstrom B, et al. Comparison of health policy documents of European cities: are they oriented to reduce inequalities in health J Public Health Policy. 2013;34:100-20.^-1313. Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change Lancet. 2014;383:630-67.

Strategies focused in intersectoral policies are indisputable from the viewpoint of its urgency and necessity, but it is insufficient when considering the growth of social problems in urban territories in medium and large cities worldwide, especially cities in poor or developing countries.¹⁴14. Heiman HJ, Smith LL, McKool M, et al. Health policy training: a review of the literature Int J Environ Public Health. 2016;13:2-12. Therefore, in addition to these strategies from the central government of a country, it is necessary to include civil society in order to execute actions to reduce social inequities that affect the levels of health of the population, especially in the poorest territories.¹⁵15. Ndumbe-Eyoh S, Moffatt H. Intersectoral action for health equity: a rapid systematic reviewBMC Public Health. 2013:13. (Accessed 13/06/2017). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830502 /.
https://www.ncbi.nlm.nih.gov/pmc/article...

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

It is worth noting that there are studies referring to HiAP, including evaluation studies of the policies implemented in several countries, mainly in Europe¹1. Stuart K, Soulsby EJL. Reducing global health inequalities Part 1 J R Soc Med. 2011;104:321-6. ⁶6. Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global Annu Rev Publ Health. 2011;32:225-36. ¹⁴14. Heiman HJ, Smith LL, McKool M, et al. Health policy training: a review of the literature Int J Environ Public Health. 2016;13:2-12.. However, few studies have shown intersectoral policies and community participation. So, this review could inform future intersectoral policies including successful experiences with the participation of civil society.

Method

A scoping review is a review method characterised by researching the existing, relevant literature, which seeks to map and summarise a series of tests to convey the range and depth of a field supported in evidence-based practice. The scoping review method has six stages: 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data; 5) collating, summarising and reporting the results; and 6) consultation with interested individuals to inform or validate study results (optional).¹⁶16 Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology Implement Sci. 2010;5:1-9.

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

1. Identifying the research question. The research question was identified as: “What policies or actions or strategies or programs, that include intersectoral actions and social participation focussing on the social determinants of health and reduction of social health inequities (SHI), which have been implemented worldwide, have shown modifications of these determinants and/or reduction of these inequities?”. In this work, intersectorality is understood as a policy and as a technical and administrative process that involves negotiation and the distribution of power, resources and capacities (technical and institutional) between different sectors. Intersectoral action is understood as not only the political intent of the government, but also managerial capacity, together with new institutional arrangements between different sectors of the administration to achieve results. Social participation is understood as organisational arrangements and practices that involve groups and organisations of civil society, particularly those that work with resource allocation for health needs.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51.

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

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

4. Charting the data. The documents selected were analysed as proposed by Andrade et al.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. for intersectoral action, as defined in Stage 1. In accordance with this conceptual framework, the following variables were defined:

• Intersectoral action (IA):

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

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

• Social Participation (SP):

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

SP-B: ombudsmen and public defenders,

SP-C: corporate councils,

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

5. Collating, summarising and reporting the results. This work used the SDH model of the CSDH-WHO¹1. Stuart K, Soulsby EJL. Reducing global health inequalities Part 1 J R Soc Med. 2011;104:321-6. ¹⁰10. WHO. Social determinants of health. Report by the Secretariat, 132nd session. Geneva: WHO; 2012. (Accessed 14/09/2016). Available at: https://www.who.int/ .
https://www.who.int/... ¹¹11. Comisión para Reducir las Desigualdades Sociales en Salud en Espana. Propuesta de políticas para reducir las desigualdades en salud en Espana Gac Sanit. 2012;26:182-9. ¹⁸18. Solar O, Irwin A. A conceptual framework for action on the social determinants of healthGeneva: WHO. Comission on Social Determinantes of Health. 2007.

19. Borrell C, Artazcoz L. Las políticas para disminuir las desigualdades en salud Gac Sanit. 2008;22:465-73.^-2020. Farrel L, Marinnetti C, Cavaco YK, et al. Advocacy for health equity: a synthesis review Milbank Q. 2015;93:392-437. as a conceptual and theoretical framework, as well as the theoretical constructs of social capital (SC)²¹21. Macinko J, Starfield B. The utility of social capital in research on health determinants Milbank Q. 2001;79:387-427. ²²22. Kawaschi I, Subramanian SV, Kim D, editors. Social capital and health. New York: Springer Science; 2008. p. 292. and the life course (LC).²³23. Hallqvista J, Lynch J, Bartleyd M, et al. Can we disentangle life course processes of accumulation, critical period and social mobility? An analysis of disadvan-taged socio-economic positions and myocardial infarction in the Stockholm Heart Epidemiology Program Soc Sci Med. 2004;58:1555-62. ²⁴24. Kuh D, Ben-Shlomo Y, Linch J, et al. Life course epidemiology J Epidemiol Community Health. 2003;57:778-83.

The SDH model is defined in two spheres: structural and intermediate determinants. Structural determinants are those linked to social stratification and include socioeconomic and political contexts and distribution of power and resources, as well as labour market, gender, ethnicity, social class and education level. Intermediate determinants include: a) material circumstances, such as housing, income level, working conditions or neighborhood; b) psychosocial circumstances, such as lack of social support, stressful situations (negative life events), poor control, etc.; c) behavioral and biological factors, such as life-threatening lifestyles; and d) the health system.¹1. Stuart K, Soulsby EJL. Reducing global health inequalities Part 1 J R Soc Med. 2011;104:321-6. ¹⁰10. WHO. Social determinants of health. Report by the Secretariat, 132nd session. Geneva: WHO; 2012. (Accessed 14/09/2016). Available at: https://www.who.int/ .
https://www.who.int/... ¹¹11. Comisión para Reducir las Desigualdades Sociales en Salud en Espana. Propuesta de políticas para reducir las desigualdades en salud en Espana Gac Sanit. 2012;26:182-9. ¹⁸18. Solar O, Irwin A. A conceptual framework for action on the social determinants of healthGeneva: WHO. Comission on Social Determinantes of Health. 2007.

19. Borrell C, Artazcoz L. Las políticas para disminuir las desigualdades en salud Gac Sanit. 2008;22:465-73.^-2020. Farrel L, Marinnetti C, Cavaco YK, et al. Advocacy for health equity: a synthesis review Milbank Q. 2015;93:392-437. Social capital is a theoretical construct developed by Macinko and Starfield²¹21. Macinko J, Starfield B. The utility of social capital in research on health determinants Milbank Q. 2001;79:387-427., and Kawaschi et al.²²22. Kawaschi I, Subramanian SV, Kim D, editors. Social capital and health. New York: Springer Science; 2008. p. 292., who took the concept social capital from contributions by thinkers like Robert Putnam, James Coleman and Pierre Bourdieu, and applied in the field of health and more specifically in the field of studies on social determinants of health. The social capital is defined as a specific form of social organisation in which a strong network of interpersonal relationships is based on reciprocity and social cooperation. This organisation produces a personal and collective development capital that determines development in all sectors: economic, cultural, political, social and health.²¹21. Macinko J, Starfield B. The utility of social capital in research on health determinants Milbank Q. 2001;79:387-427. ²²22. Kawaschi I, Subramanian SV, Kim D, editors. Social capital and health. New York: Springer Science; 2008. p. 292.

The theoretical construct of life course understands that the socioeconomic inequities present in certain regions have a lifelong effect on people born and raised in these regions. Thus, life course epidemiology is defined as the study of long-term effects on health or disease risk of physical or social exposures during gestation, childhood, adolescence, young adulthood and later adult life.²³23. Hallqvista J, Lynch J, Bartleyd M, et al. Can we disentangle life course processes of accumulation, critical period and social mobility? An analysis of disadvan-taged socio-economic positions and myocardial infarction in the Stockholm Heart Epidemiology Program Soc Sci Med. 2004;58:1555-62. ²⁴24. Kuh D, Ben-Shlomo Y, Linch J, et al. Life course epidemiology J Epidemiol Community Health. 2003;57:778-83.

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

Results

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

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

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

According to the variables, 12 documents reported intersectoral action associated with social participation SP, in any of their categories.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁵25. Baum F, Lawless A, MacDougall C, et al. New norms new policies: did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and health in all policies Soc Sci Med. 2015;147:1-9.

26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98.

27. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services Aust N Z J Public Health. 2014;38:553-9.

28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42.

29. Prasad A, Groot AMM, Monteiro T, et al. Linking evidence to action on social determinants of health using Urban Heart in the Americas Rev Panam Salud Publica. 2013;34:407-15.

30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8.

31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43.

32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017).

33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37.

34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67.^-3535. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54. Four documents reported local community-based social participation actions in partnership with different institutions.³⁵35. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54.

36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62.

37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61.^-3838. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45. Three documents referred exclusively to intersectoral action conducted only by central government policies, without community participation³⁹39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ⁴²42. Muñoz TH. Acciones sobre los determinantes sociales de la salud en Venezuela Revista Cubana de Salud Pública. 2010;36:366-71. ⁴³43. Lawless A, Williams C, Hurley K, et al. Health in all policies: evaluating the South Australian approach to intersectoral action for health Can J Public Health. 2012;103 (Suppl 1):S15-9. (Table 2).

Regarding their theoretical frameworks, eight documents reported on intersectoral actions and social participation pertaining to CSDH and SC.²⁵25. Baum F, Lawless A, MacDougall C, et al. New norms new policies: did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and health in all policies Soc Sci Med. 2015;147:1-9. ²⁶26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98. ³⁰30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8.

31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43.

32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017).

33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37.

34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67.^-3535. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54. Three documents showed the actions taken were included in all three (CSDH, SC, LC).¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁷27. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services Aust N Z J Public Health. 2014;38:553-9. ²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. Two documents showed actions inserted within SC.³⁶36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62. ⁴⁰40. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88. One included the CSDH and LC.⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14. And five only included references to the CSDH²⁹29. Prasad A, Groot AMM, Monteiro T, et al. Linking evidence to action on social determinants of health using Urban Heart in the Americas Rev Panam Salud Publica. 2013;34:407-15. ³⁸38. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45. ³⁹39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ⁴²42. Muñoz TH. Acciones sobre los determinantes sociales de la salud en Venezuela Revista Cubana de Salud Pública. 2010;36:366-71. ⁴³43. Lawless A, Williams C, Hurley K, et al. Health in all policies: evaluating the South Australian approach to intersectoral action for health Can J Public Health. 2012;103 (Suppl 1):S15-9. (Table 2).

In relation to the reduction in SHI, studies showed numerous improvements, including: increased access to health and education; follow-up of pregnant women and increase in prenatal examinations; reduction in malnutrition and child mortality; reduction in extreme poverty and hunger; a reduction in epidemics; ¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. ³⁰30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8. ³²32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017). ³⁵35. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54.

36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62.

37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61.^-3838. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45. ⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14. reduction in infectious diseases, such as tuberculosis;³⁹39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14. control of problematic use of alcohol and other drugs;³⁶36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62. ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. promotion of health and mental health and improvements in health care and mental health;³⁶36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62. ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. ⁴⁰40. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88. ⁴³43. Lawless A, Williams C, Hurley K, et al. Health in all policies: evaluating the South Australian approach to intersectoral action for health Can J Public Health. 2012;103 (Suppl 1):S15-9. environmental improvements and basic sanitation in vulnerable regions;³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. creation of healthy habits among populations and social groups;³⁸38. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45. increasing in social capital; increasing in social protection and access to healthcare for vulnerable population, reduction of violence and creation of safer areas.²⁵25. Baum F, Lawless A, MacDougall C, et al. New norms new policies: did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and health in all policies Soc Sci Med. 2015;147:1-9. ²⁷27. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services Aust N Z J Public Health. 2014;38:553-9. ²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. ³²32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017). ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. ⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14.

Other works revealed: increasing in health promotion actions and physical activities;²⁴24. Kuh D, Ben-Shlomo Y, Linch J, et al. Life course epidemiology J Epidemiol Community Health. 2003;57:778-83. decreasing in cardiovascular risk factors; renovation of physical areas in neighbourhoods to facilitate access to services; increasing in the number of day care centres providing high-quality care to children; increasing in access to healthy food; prevention of HIV transmission between mother and child and reducing noncommunicable diseases; installation of central heating systems to increase health status and quality of life in vulnerable neighbourhoods.²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. ³⁰30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8. ³¹31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43. ³⁵35. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54. ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. ³⁹39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14.

Other authors showed up socioeconomic improvements, increasing in access to educationand other social services, accessing to healthy food, decreasing in barriers to gender, reduction of extreme poverty and employment generation.²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. ³³33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37. ³⁴34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67. ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61. ⁴¹41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14. ⁴³43. Lawless A, Williams C, Hurley K, et al. Health in all policies: evaluating the South Australian approach to intersectoral action for health Can J Public Health. 2012;103 (Suppl 1):S15-9.

Finally, other studies tackled SDH such as creation of agendas for confronting racism, promoting actions that improved social capital, education, transportation, employment, food access, housing, environmental exposure and access to healthcare services.³⁰30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8. ⁴²42. Muñoz TH. Acciones sobre los determinantes sociales de la salud en Venezuela Revista Cubana de Salud Pública. 2010;36:366-71. ⁴³43. Lawless A, Williams C, Hurley K, et al. Health in all policies: evaluating the South Australian approach to intersectoral action for health Can J Public Health. 2012;103 (Suppl 1):S15-9.

Discussion

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

According to the variables of this research, there is a prevalence of studies on intersectoral actions developed together with community participation (nongovernmental social organizations and civil society), which add up to 12 documents from the 20 analyzed.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁵25. Baum F, Lawless A, MacDougall C, et al. New norms new policies: did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and health in all policies Soc Sci Med. 2015;147:1-9.

26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98.

27. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services Aust N Z J Public Health. 2014;38:553-9.

28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42.

29. Prasad A, Groot AMM, Monteiro T, et al. Linking evidence to action on social determinants of health using Urban Heart in the Americas Rev Panam Salud Publica. 2013;34:407-15.

30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8.

31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43.

32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017).

33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37.

34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67.^-3535. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54.This recommendation is particularly emphasized in some of the reviewed studies¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ³⁷37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61.

38. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45.

39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ^-4040. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88. and also by studies that do not address specific intersectoral actions but underline the need for intersectoral strategies to be necessarily accompanied by social participation (local decision-makers and community membership).⁶6. Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global Annu Rev Publ Health. 2011;32:225-36. ⁴⁴44. Lorenc T, Tyner EF, Patticrew M, et al. Cultures of evidence across policy sectors: systematic review of qualitative evidence Eur J Public Health. 2014;27:1-7.

45. Campos-Matos I, Russo G, Perelman J. Connecting the dots on health inequalities - a systematic review on the social determinants of health in Portugal Int J Equity Health. 2016;15:26.^-4646. Tess BH, Aith FMA. Intersectorial health-related policies: the use of a legal and theoretical framework to propose a typology to a case study in a Brazilian municipality Cien Saude Colet. 2014;19:4449-56. It is interesting to note that four studies ³⁶36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62.

37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61.

38. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45.

39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ^-4040. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88. presented territorial intersectoral strategies in areas in neighbourhoods, which did not originate from central government policies, but were the result of the local community organization and stakeholders. These studies based their analysis on the argument that strong cohesion and production of a social capital, in addition to economic improvements, is very important for reducing social inequities in certain areas, especially when problems involve violence, poverty and security.²⁰20. Farrel L, Marinnetti C, Cavaco YK, et al. Advocacy for health equity: a synthesis review Milbank Q. 2015;93:392-437. ⁴⁰40. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88. ⁴⁷47. Souza EM, Grundy E. Health promotion, social epidemiology, and social capital: associations and perspectives for public health Cad Saude Publica. 2004:20. (Accessed 20/06/2017). Available at: http://www.scielosp.org/scielo.php?script=sci arttext&pid=S0102-311X2004000500030 .
http://www.scielosp.org/scielo.php?scrip... ⁴⁸48. Helal DH, Neves JAB. Superando a pobreza: o papel do capital social na Região Metropolitana de Belo Horizonte Cadernos EBAPE.BR. 2007:5. (Accessed 15/10/2016). Available at: http://bibliotecadigital.fgv.br/ojs/index.php/cadernosebape/issue/view/577 .
http://bibliotecadigital.fgv.br/ojs/inde...

Although intersectorality is denoted as essential to obtain good results from the policies implemented, the studies indicate that important administrative and managerial difficulties need to be overcome. The problems highlighted concern difficulties in surmounting a prevailing sectoral logic that makes cooperation, distribution of responsibilities and operational actions unfeasible. Moreover, difficulties related to governments promoting the decentralisation of power and deliberative capacity to intersectoral forums and obstacles to civil society organising itself in a cohesive manner to claim its rights to increased political power, are important factors.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁶26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98. ⁴⁵45. Campos-Matos I, Russo G, Perelman J. Connecting the dots on health inequalities - a systematic review on the social determinants of health in Portugal Int J Equity Health. 2016;15:26. ⁴⁹49. Akerman M, Franco de Sá R, Moysés S, et al. Intersetoriality? Intersetorialities? Cien Saude Colet. 2014;19:4291-300.

Andrade et al.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. presented as a complication in the implementation of intersectoral projects, the fact of the technical unpreparedness of managers. The need to create a cooperativeculture in management and administrative relationships, together with technical training for intersectoral management, is fundamental.

According to our theoretical framework, eight documents reported on intersectoral actions and social participation using as theoretical reference of the SDH model of the CSDH-WHO associated with the social capital.²⁵25. Baum F, Lawless A, MacDougall C, et al. New norms new policies: did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and health in all policies Soc Sci Med. 2015;147:1-9. ²⁶26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98. ³¹31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43.

32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017).

33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37.

34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67.^-3535. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54. This data can be interpreted by associating the result referring to the variables, that is, the studies strongly emphasized the need to develop intersectoral actions associated with social participation and the importance of besides the economic social determinants also to strengthen the social bondsof the community involved in the project.

According to reduction in social health inequities, studies reviewed showed improvements in the following main areas: increased access to health services, increase in prenatal examinations, reduction in malnutrition and child mortality, prevention and reduction communicable and noncommunicable diseases, reduction in epidemics, prevention on HIVtransmission, decrease in cardiovascular risk factors, increase access to healthy food. Positive results were also presented: increasing in access to education, transportation, housing, healthy environment, reduction of violence and creation of safer areas, reduction of poverty, socioeconomics improvements, decreased barriers to gender, employment, increase of social capital, etc.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁶26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98.

27. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services Aust N Z J Public Health. 2014;38:553-9.

28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42.

29. Prasad A, Groot AMM, Monteiro T, et al. Linking evidence to action on social determinants of health using Urban Heart in the Americas Rev Panam Salud Publica. 2013;34:407-15.

30. Clavier C, Gendron S, Lamontagne L, et al. Understanding similarities in the local implementation of a health environment programme: insights from policy studies Soc Sci Med. 2012;75:171-8.

31. Baril N, Patterson M, Boen C, et al. Building a regional health equity movement. The Grantmaking Model of a Local Health Department Fam Community Health. 2011;34 (Suppl 1):S23-43.

32. Díaz C, Torres Y, De la Cruz AM, et al. Estrategia intersectoral y participativa con enfoque para la prevención de la transmición de dengue en local Cad Saude Publica. 2009;25(Suppl 1):S59-70. (Accessed 13/06/2017).

33. Lal S, Mercier C. Intersectoral action to employ individuals with mental illness: lessons learned from a local development initiative Work. 2009;33:427-37.

34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67.

35. Wimmer GF, Figueiredo GO. Collective action for quality of life: autonomy, trans- disciplinarity and intersetorality Cien Saude Colet. 2006;11:145-54.

36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62.

37. Eugenio JL, Mendoza MLM, Figueroa IV, et al. Movilización social y determinantes sociales de la salud: proceso educativo en comunidad rural de Jalisco, México Revista de Estudios Sociales. 2015;23:139-61.

38. Alia K, Freedmam DA, Brandt HM, et al. Identifying Emergent Social Networks at a Federally Qualified Health Center-Based Farmers’ Market Am J Community Psychol. 2014;53:335-45.

39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article...

40. Mendel P, Ngo VK, Dixon ERN, et al. Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities Ethn Dis. 2011;21:78-88.

41. Nascimento PR, Westphal MF, Moreira RS, et al. Impact of the social agendas-Agenda 21 and Healthy Cities- upon social determinants of health in Brazilian municipalities: measuring the effects of diffuse social policies through the dimensions of the Millennium Development Goals Rev Bras Epidemiol. 2014;17 (Suppl 2):1-14.^-4242. Muñoz TH. Acciones sobre los determinantes sociales de la salud en Venezuela Revista Cubana de Salud Pública. 2010;36:366-71. So according to the studies the overall results were positive and many advances in relation to the social determinants of health can be observed.⁵⁰50. Covadia H, Jewkes R, Barron P, et al. The health and health system of South Africa: historical roots of current public health challenges Lancet. 2009;374:817-34. ⁵¹51. Kolahdooz F, Nader F, Kyoung J, et al. Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions Glob Health Action. 2015;8:27966.

Although advances can be verified in many countries, social inequities are still predominant factors marking health inequities and obstacles to the establishment of equity.¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51. ²⁸28. García-Ramírez JA, Vélez-Álvarez C. América Latina frente a los determinantes sociales de la salud: políticas públicas implementadas Rev Salud Publica. 2013;15:731-42. ³⁴34. Manandhar M, Maimbolwa M, Muulu E, et al. Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia Health Promot Int. 2008;24:58-67. ³⁶36. Diba D, D’Oliveira AF. Teatro e comunidade, juventude e apoio social: atores da promoção da saúde Cien Saude Colet. 2015;20:1353-62. ⁴²42. Muñoz TH. Acciones sobre los determinantes sociales de la salud en Venezuela Revista Cubana de Salud Pública. 2010;36:366-71. In poor countries, policies that address the social determinants of health and the reduction of inequities are fragmented and show discontinuity in their implementation, management and inspection. Local governments show important differences in the pace and demarcation of priorities with which policies are implemented, creating gaps between regions in the same country.⁵²52. Giovanella L, Stemüler K. The financial crisis and healthcare sys- tems in Europe: universal care under treat? Trends in health sector reforms in Germany, the United Kindom, and Spain Cad Saude Publica. 2014:30. (Accessed 13/06/2017). Available at: http://www.scielosp.org/pdf/csp/v30n11/0102-311X-csp-30-11-2263.pdf .
http://www.scielosp.org/pdf/csp/v30n11/0... ⁵³53. Hernández-Aguado I, Cesteros MS, Esteban PC. Las desigualdades sociales en salud y la atención primaria. Informe SESPAS 2012 Gac Sanit. 2012;26 (Supl 1):6-13. Concerning Latin American countries, there are problems related to strong cultural, ethnic and gender issues, and poverty which need to be addressed in order to implement intersectoral projects aimed at producing health equity.²2. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the CSDH. Geneva: World Health Organization; 2008. (Accessed 14/09/2016). Available at: http://www.who.int/social determinants/thecommission/finalreport/en
http://www.who.int/social determinants/t... ¹⁷17. Andrade LOM, Pellegrini-Filho A, Solar O, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries Lancet. 2015;385:1343-51.

Although studies show that important SDH policies in Europe have been successfully implemented there are significant disparities between Eastern and Western Europe. Eastern European countries present health problems and inequities in health access that are as severe as the world's poorest countries.⁴4. Barros A, Rosmans C, Axelson H, et al. Equity in maternal, newborn and child health intervention in Countdonw to 2015: a retrospective review of survey data from 54 countries Lancet. 2012;379:225-33. ⁶6. Friel S, Marmot MG. Action on the social determinants of health and health inequities goes global Annu Rev Publ Health. 2011;32:225-36. ²⁶26. Farrington JL, Faskunter J, Mackiewicz K. Evaluation of risks factor in a European City Network Health Promot Int. 2015;30 (Suppl 1):86-98. ⁵²52. Giovanella L, Stemüler K. The financial crisis and healthcare sys- tems in Europe: universal care under treat? Trends in health sector reforms in Germany, the United Kindom, and Spain Cad Saude Publica. 2014:30. (Accessed 13/06/2017). Available at: http://www.scielosp.org/pdf/csp/v30n11/0102-311X-csp-30-11-2263.pdf .
http://www.scielosp.org/pdf/csp/v30n11/0... Similar to Eastern Europe, other studies reiterate that Iberian countries have high rates of health inequities.¹³13. Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change Lancet. 2014;383:630-67. ¹⁸18. Solar O, Irwin A. A conceptual framework for action on the social determinants of healthGeneva: WHO. Comission on Social Determinantes of Health. 2007. ⁴⁵45. Campos-Matos I, Russo G, Perelman J. Connecting the dots on health inequalities - a systematic review on the social determinants of health in Portugal Int J Equity Health. 2016;15:26. ⁵²52. Giovanella L, Stemüler K. The financial crisis and healthcare sys- tems in Europe: universal care under treat? Trends in health sector reforms in Germany, the United Kindom, and Spain Cad Saude Publica. 2014:30. (Accessed 13/06/2017). Available at: http://www.scielosp.org/pdf/csp/v30n11/0102-311X-csp-30-11-2263.pdf .
http://www.scielosp.org/pdf/csp/v30n11/0...

53. Hernández-Aguado I, Cesteros MS, Esteban PC. Las desigualdades sociales en salud y la atención primaria. Informe SESPAS 2012 Gac Sanit. 2012;26 (Supl 1):6-13.^-5454. Marmot MG, Allen J, Bell R, et al. WHO European review of social determinants of health and the health divide Lancet. 2012;380:1011-29. It is interesting to note that all the documents initially collected had titles containing the central theme of the social determinants of health, social inequities and mentioned or recommended intersectorality as a coping strategy. However, only 20 documents focused directly on policies, strategies and/or actions that concretely applied intersectoral programmes focused on the social determinants of health and were combined with social participation. This observation is reinforced by the work of Pons-Vigués et al.³⁹39. Pons-Vigués M, Diez E, Morrison J, et al. Social and health policies or interventions to tackle health inequalities in European cities: a scoping review BMC Public Health. 2014:14. (Accessed 20/10/2016). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938820 /.
https://www.ncbi.nlm.nih.gov/pmc/article... , which emphasizes the current tendency of an increase in academic-scientific productions on this subject, while countries still face enormous difficulties in achieving intersectoral experiences. This is due to the strong impregnation of the anachronistic logics of state and governance management, fragmented and cemented in sectorial interests, as well as the highly centralised manifestation of political power in national governments, without the necessary decentralisation of power to local governments and civil society. These observations were also mentioned by other studies.⁵⁵55. Pellegrini Filho A. Public policy and social determinants of health: the challenge of the production and use of scientific evidence Cad Saude Publica. 2011;27 (Suppl 2). (Accessed on 13/06/2017). Available at: http://www.scielo.br/pdf/csp/v27s2/02.pdf .
http://www.scielo.br/pdf/csp/v27s2/02.pd... ⁵⁶56. Villar E. Los determinantes sociales de la salud y la lucha por la equidad en salud: desafíos para el Estado y la sociedad civil Saúde e Sociedade. 2007:16. (Accessed 20/06/2017). Available at: http://www.scielo.br/pdf/sausoc/v16n3/02.pdf .
http://www.scielo.br/pdf/sausoc/v16n3/02...

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

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

One limitation of this research is the range of studies reviewed; expansion of the search strategies in other databases is important so that studies in other regions of the planet can be analysed. The revised documents are predominantly derived from research developed in countries of the Western world. In addition, the literature evaluating or describing the impact of intersectoral actions on health is limited, something that has been observed by other review studies.¹⁵15. Ndumbe-Eyoh S, Moffatt H. Intersectoral action for health equity: a rapid systematic reviewBMC Public Health. 2013:13. (Accessed 13/06/2017). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830502 /.
https://www.ncbi.nlm.nih.gov/pmc/article... ⁵¹51. Kolahdooz F, Nader F, Kyoung J, et al. Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions Glob Health Action. 2015;8:27966.

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

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

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