Action on the Social Determinants of Health: The Role of Local Public Health Units

1. Action on the Social Determinants of Health: The Role of Local Public Health Units Dennis Raphael, PhD School of Health Policy and Management York University Presentation to the Peterborough County/City Board of Health, Peterborough, Ontario October 12, 2011

2. Overview of Presentation • The importance of the social determinants of health (SDH) • Type 2 diabetes as an illustration of the importance of the SDH in incidence and management of the disease • The role of public health units in educating and mobilizing the public to address the SDH

3. What are Social Determinants of Health? • Social determinants of health are the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole. • Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.

4. Aboriginal status disability early life education employment and working conditions food security health services gender housing income and income distribution race social exclusion social safety net unemployment The Canadian Perspective Source: Mikkonen, J. andRaphael, D. (2010). Social Determinants of Health: The Canadian Facts. On-line at http://thecanadianfacts.org

5. Social Determinants of Health SDOH can affect health in a number of ways: • Social determinants define the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society; • Social determinants can cause stress and anxiety which can damage people’s health; • Social determinants limit peoples’ choices and militates against desirable changes in behaviour. Source: Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

6. Poverty is the clustering of exposures to adverse social determinants of health(not to belabour the point, but very few poor people live in mansions and eat “healthy” diets and very few rich people are at risk of homelessness or going hungry)

7. Social determinants of health (SDH) are the primary factors shaping health

8. Diabetes prevalence by age and income 18.00% 16.00% 14.00% 12.00% NO INCOME or < $29,999 10.00% $30,000-$79,999 Prevalence 8.00% $80,000 or more 6.00% 4.00% 2.00% 0.00% 20 - 29 30 - 44 45 - 59 60+ Source: Statistics Canada Canadian Community Health Survey

9. Source: Adapted from Dinca-Panaitescu, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). Diabetes prevalence and income: Results of the Canadian Community Health Survey. Health Policy, 99, 116–123

10. Source: Adapted from Dinca-Panaitescu, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). Diabetes prevalence and income: Results of the Canadian Community Health Survey. Health Policy, 99, 116–123

11. Dinca-Panaitescua, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). The dynamics of the relationship between poverty experience and type 2 diabetes: Longitudinal results. York University: SHPM.

12. SDH shape access to care, management of illness, and recovery from illness

13. Source: Wilkins, R. (2007). Mortality by Neighbourhood Income in Urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar, and Special Compilations.

14. Source: Wilkins, R. (2007). Mortality by Neighbourhood Income in Urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar, and Special Compilations.

15. SDOH of Type 2 Diabetes Study • Objectives: • Examine the experiences and living conditions of low-income persons with type 2 diabetes. • Place findings in the context of the social determinants of health. • Methodology: • 60 in-depth interviews with individuals with Type 2 Diabetes and focus groups with service providers. • Thematic analysis of interview content. • Also, content analysis according to key social determinants.

16. Food 72% of participants indicated that they lacked the economic resources required to acquire the kind of diet they knew they must follow.

17. Food I. Do you have enough money to get the kind of food you’d like to get? P. Not really. [laughs] No money. Plus the rent is high too. So I haven’t got very much you know. I. So it doesn’t leave you a lot of money. P. No. That’s why I go to the church and, sometimes they give you-- they have stuff on the table, like some groceries you take. I. Hmm. Do you find that sometimes you have to eat food that you know you probably shouldn’t eat? P. Yeah. But I don’t eat donuts and stuff, because it’s got a lot of sugar, right? They say that everything you eat, you know, turns into sugar except the vegetables. [ male, 53 years]

18. Social Assistance Levels do not Allow for Health

20. Source: Food Banks Canada (2011). Hunger Count. Toronto: Food Banks Canada.

21. Adverse SDH and Public Policy The Canadian Public Health Association: “Policies shape how money, power and material resources flow through society and therefore affect the determinants of health. Advocating healthy public policies is the most important strategy we can use to act on the determinants of health.”

22. Citizen involvement is a primary means of influencing the quality of the SDH and affecting health and health care outcomes

23. The Role of Public Health Units

24. Ontario Public Health Standards 2009 • Addressing determinants of health and reducing health inequities are fundamental to the work of public health in Ontario. • Effective public health programs and services consider the impact of the determinants of health on the achievement of intended health outcomes.

25. Ontario Public Health Standards 2009 • The board of health shall provide population health information, including determinants of health and health inequities to the public, community partners, and health care providers, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). • Dissemination of surveillance analyses may take the form of reports, advisories, healthy public policy recommendations, alerts, or warnings.

26. The Way Forward Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.Source: Commission on the Social Determinants of Health. (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants Of Health. Geneva: World Health Organization.

27. In a 2010 survey of the 36 public health units in Ontario, only two of the 23 responding units had undertaken “community education and awareness campaigns” about the SDH

30. Canadian Democracy! • It shall be lawful for the Queen, by and with the Advice and Consent of the Senate and House of Commons, to make Laws for the Peace, Order, and good Government of Canada – Canadian Constitution1867/1982 • “Citizens in a democracy have the right -- even obligation -- to participate meaningfully in public decision-making and to be informed about the bases of government policies.” • Frank Fischer. Reframing Public Policy 2003

31. Summary: The Social Determinants of Health • Social determinants of health (SDH) are the primary factors shaping health • SDH shape access to care, management of illness, and recovery from illness • Citizen involvement is a primary means of influencing the quality of the SDH and affecting health and health care outcomes • Public health units have an important role in public education about the SDH

32. Learn more…

36. thecanadianfacts.org

37. Dennis Raphaeldraphael@yorku.caThis presentation and other presentations and related papers are available at:http://www.atkinson.yorku.ca/draphael[go to the library there]