Taking action on P overty as a Determinant of Health

1. Laura Hanson, RN, MN 16th Annual Ontario Family Practice Nurses Conference May 4, 2012 Taking action on Poverty as a Determinant of Health

2. THANK YOU!

3. Health Providers Against Poverty

4. Overview • Overview of poverty and health inequity in Ontario. • Interventions for individuals you see in primary care • Political action to address roots of poverty

5. Key Messages • Income inequality, a political issue, is the single most important social determinant of health. • Nurses must take action to address poverty as a high impact health promotion and disease prevention strategy.

6. What does it mean to be poor in Ontario? • Income inequality and poverty are realities for almost 2 million people across urban and rural Ontario. • Poverty disproportionately affects lone parent families, people of colour, people with disabilities, transgender people and Aboriginal people. • Poverty affects children, youth, adults and seniors.

7. Poverty affects working people and people on social assistance. • Income inequality has been increasing in Canada for the past three decades. • Poverty is created by systemic factors and policy decisions.

8. In Ontario: • Social assistance rates cut 21% 1995 • Despite 9% increase since 2004, rates have fallen by 55% since then • # single people on OW increased by > 60% since 2000 • Ont spending 27% LESS on OW than 1994 (Ontario Federation of Labour)

9. In Ontario • Ontario Works - $634/month – 36% of min wage • Ontario Disability Support Program – approx $1020/month • Provide 34% - 58% of poverty line rates

10. Current economic realities • 1 in 10 men out of work • 1 in 14 women out of work • 300,000 manufacturing jobs lost since 2005 • People working full time for minimum wage still fall below the poverty line.

11. Meeting basic needs: Food • The average cost of nutritious food for a family of four in South western Ontario is about $776.37 per month (Elgin St. Thomas Public Health Unit) • Family of four on Ontario Works gets about $2000 per month: $1234 left for rent, transportation, personal hygiene supplies, clothing, etc • Full time minimum wage earner: $1000 left for other expenses (before tax credits and child benefit)

12. Meeting basic needs: Shelter • The average rent for a bachelor apartment in Toronto is around $819 per month (Canadian Mortgage and Housing Corporation) • Leaves -$185 for a person on Ontario Works • People on Ontario Disability Support Program have $234 for all other basic needs

13. Reflection: What do you think about the relationship between poverty and health ? • Is poverty the cause or outcome of illness? • Is it low incomes or “lifestyle” that produces disease and poor health?

14. World Health Organization (2008) Inequity in the conditions of daily lives is shaped by deeper social structures and processes; the inequity is systematic, produced by policies that tolerate or actually enforceunfair distribution of and access to power, wealth, and other necessary social resources. Public Health Agency of Canada (2004) There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be themost important determinants of health.

15. Heart Disease In Toronto, men in the lowest income group have a premature mortality rate from cardiovascular disease 13% above the overall rate for Ontario If everyone had the premature mortality rate of the highest income group, there would be 21% fewer premature deaths from heart disease. McKeown, D., et. al. (2008) Toronto Public Health: Unequal City: Income and Health Inequalities in Toronto.

16. Diabetes Prevalence of diabetes is more than double in the lowest income group compared to highest income group Deaths related to diabetes are 70% higher for low income women and 58% higher for low income men. Bierrman AS, Ahmad F, Angus J, Glazier RH, Vahabi M, Damba C, Dusek J, Shiller SK, Li Y, Ross S, Shapiro G, Manuel D. (2009) Burden of Illness. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 63

17. Cancer Lower income groups have: • higher rates of oral, lung and cervical cancer • lower 5 year survival rates for most cancers • more barriers to cancer screening tests such as Paps and mammograms Krzyzanowska, M.K., et. al. (2009) Cancer. In Bierman, A.S., editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1. Toronto, 35 . Conway, D.I., et. al. (2008) “Socioeconomic inequalities and oral cancer risk: A systematic review and meta-analysis of case-control studies,” International Journal of Cancer, 122, 2814.  Shack, L., et. al.,.(2008) ”Variation in incidence of breast, lung and cervical cancer and malignant melanoma of skin by socioeconomic group in England,” BMC Cancer, 8, 271.  Singh, G.K., et. al.,(2003) ”Area Socioeconomic Variations in US Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999,” NCI Cancer Surveillance Monograph Series,No. 4. Bethesda, Md: National Cancer Institute, 95.

18. Mental Health • Prevalence of depression is 58% greater in lower income populations compared to the Canadian average • Suicide attempt rates are 18 times higher for social assistance recipients than for people with higher incomes Smith, et. al., (2007) “Gender, Income and Immigration Differences in Depression in Canadian Urban Centres,” Canadian Journal of Public Health, 98(2), 149. Lightman, E., Mitchell, A. & Wilson, B.. (2009) Sick and Tired: The Compromised Health of Social Assistance Recipients and the Working Poor in Ontario. Wellesley Institute, Toronto, 12.

19. Chronic Disease and Disability • The poorest Canadians are twice as likely to have multiple chronic healthconditions compared to those with the most income. • Canadians with the least income have significantly more disability days that those with higher incomes. Lightman, E., Mitchell, A. & Wilson, B.Poverty is making us sick: A comprehensive survey of income and health in Canada. Wellesley Institute, Toronto, 2008:

20. Percentage of Adults who reported having selected chronic diseases by sex and annual household income, Ontario 2005 Bierman AS, Ahmad F, Angus J, Glazier RH, Vahabi M, Damba C, Dusek J, Shiller SK, Li Y, Ross S, Shapiro G, Manuel D. (2009) Burden of Illness. In: Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 63

21. Income and health • Effects of poverty last over time: low income children have increased risk of heart disease as adults even if they climb out of poverty • (Raphael and Farrell; Davey-Smith and Gordon)

22. Mortality www.healthydebate.ca

23. Evidence on Poverty and Health • Extensive research has overwhelmingly demonstrated that poverty and lower income levels determine health most powerfully. • Multiple systemic barriers mean that people cannot “pull themselves out of poverty”.

24. Reflection • Can you think of an experience or story, personal or professional, that shows the link between income inequality and health?

25. A health care system – even the best health care system in the world – will be only one of the ingredients that determine whether your life will be long or short, healthy or sick, full of fulfillment, or empty with despair. – The Honourable Roy Romanow, 2004

26. Primary Care Nursing interventions to addressing poverty • There are many different settings where you will see clients living in poverty. • How do you know that the health of your clients is not impacted by poverty? • It is important not to make assumptions but rather ask the right questions: “Do you ever have difficulty making ends meet at the end of the month?”

27. Ask! (gently, and with an intervention/plan in mind): • What is your income? • Where are you staying right now? • Do you have money for your medication? • Do you ever go without meals? • Do you have bus fare or a way to get to your next appointment?

28. Preventive Care Checklist: SDOH Determinants of Health: HOUSING: INCOME (EMPLOYED/OW/ODSP):  FOOD SECURITY:WORK/OCCUP.HEALTH RISKS:  SOCIAL SUPPORTS:FAMILY/RELATIONSHIP: Drug Insurance: WELFARE SUPPLEMENTS (E.G. DIET, TRANSPORTATION, SUPPLIES): www.healthprovidersagainstpoverty.ca • Tools and Resources • “Sample preventive care checklist...” for women and men template endorsed by CFPC

29. Community Resources What are the available resources in your community? • Emergency shelters • Respite, infirmary for homeless people • Food banks • Meal programs • Compassionate pharmaceutical programs • Subsidized housing Do you advocate to ensure your clients get the services they need?

30. Poverty = Modifiable Risk Factor • Annual increase of $1,000 in income for the poorest twenty percent of Canadians  10,000 fewer chronic conditions  6,600 fewer disability days every two weeks • = extra $20/week (Lightman et al, 2008)

31. Poverty: A clinical tool for primary care

34. Best practices for completing ODSP applications www.healthprovidersagainstpoverty.ca • Tools and resources • “Best Practices for Completing successful ODSP applications 2005”

35. How do you support people living in poverty in your practice?

36. Primary Care versus Primary Health Care Primary health care refers to an approach to health and a spectrum of services beyond the traditional health care system. It includes all services that play a part in health, such as income, housing, education, and environment. Primary care is the element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury. (Health Canada)

37. Political action on Poverty • Poverty elimination is “good medicine (health care)”. • Long term costs exceed short term expense

39. Nightingale • Used her social class to write to bureaucrats and politicians re social conditions • Eg improved air quality in 19th century British work houses

40. Lillian Wald/Lavinia Dock • New York tenements, mostly immigrant poor • Fought for health care, tenement improvements, abolition child labour • Dock co-founded United Garment Workers’ union, birth control • Jailed 3 times for suffrage demonstrations

41. Hunger Clinic-Queen’s Park

42. Special Diet Campaign

43. Direct Action &working with anti-poverty groups

44. Research, media work & public awareness 2012 City of Toronto Budget: Analysis Cuts to affordable housing Issue: • City of Toronto 2012 Budget1 proposes cuts to Shelter, Support and Housing Administration (SSHA), including2 the following recommendations3: o Reduction in the Shelter, Support and Housing department budget by 15%, with the biggest percentage cut (45%) in the affordable housing program o Reduction in spending by the Affordable Housing Office by 10.6% leading to a decrease in new affordable housing development (1,502 homes this year to 300 new homes by 2014) o Reduction in funding to repair rundown housing (from 1,034 homes repaired this year to 400 by 2013)...

45. Call to action on SDOH • Share your observations and creative interventions with your colleagues/students – case conferences, care plans, AHE templates • Be alert to patterns, think about upstream work - if your practice supports research, think of ways to document health costs of poverty, or feed ideas to research colleagues

46. Call to action on SDOH • If your practice supports upstream work, or you have personal energy to do it, add credible nursing voices to political advocacy campaigns • RNAO participates actively in SDOH advocacy – encourage OFPN to add its voice

47. Join Us! • www.healthprovidersagainstpoverty.ca

48. Case Study: Inner City Community Level • Inner city FHT • Large pop’n homeless, rooming houses, boarding homes, ppl with ongoing mental health issues • Resp and cardiac issues during heat waves

49. Case Study: Inner City Community Level • Elderly client died last summer heat related illness - schizophrenia, risperidone • Today: 40C with Humidex, at least next 3 days • Homeless people seeking shelter under shade trees in park – works staff