1

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

Health Units

Dennis Raphael, PhDSchool 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

The Canadian Perspective • 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

Source: Mikkonen, J. and Raphael, 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

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20 - 29 30 - 44 45 - 59 60+

Source: Statistics Canada Canadian Community Health Survey

Prev

alen

ce NO INCOME or < $29,999

$30,000-$79,999

$80,000 or more

9

Figure 4. Increased Risk of Type 2 Diabetes for Lower Income Men not Affected by Weight or Physical Activity

2.07 1.94 1.72 1.66

0

1

2

3

Income <$15,000

Education,Weight, and

Physical ActivityTaken into

Account

Income $15,000-29,999

Education,Weight, and

Physical ActivityTaken into

Account

Lower Income Groups

Incr

ease

d R

isk

of

Ty

pe 2

Dia

bete

s

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

Figure 5. Increased Risk of Type 2 Diabetes for Lower Income Women Slightly Affected by Weight and Physical Activity

3.572.75 2.58

2.1

0

12

3

4

Income <$15,000

Education,Weight, and

PhysicalActivity Takeninto Account

Income $15,000-29,999

Education,Weight, and

PhysicalActivity Takeninto Account

Lower Income Groups

Incr

ease

d R

isk

of T

ype

2 D

iabe

tes

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

Figure 6. Increased Risk of Developing Type 2 Diabetes over a two year Period for Canadians Living in Poverty

1.24 1.28 1.26 1.24

0

0.5

1

1.5

Living inPoverty DuringPeriod Prior to

DevelopingDiabetes

Adjusted forObesity and

PhysicalInactivity

Living inPoverty at Any

Time Duringthe Course of

the Study

Adjusted forObesity and

PhysicalActivity

Poverty Situation

Incr

ease

d R

isk

of T

ype

2 D

iabe

tes

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

Figure 1. Diabetes Mortality, Urban Canada, 1971-2001, Males

0

5

10

15

20

25

1971 1976 1981 1986 1991 1996 2001

Mor

talit

y R

ates

Per

100

,000

Q1 - RichestNeighbourhoods

Q2

Q3

Q4

Q5 - PoorestNeighbourhoods

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

Figure 2. Diabetes Mortality, Urban Canada, 1971-2001, Females

0

5

10

15

20

25

1971 1976 1981 1986 1991 1996 2001

Mor

talit

y R

ates

Per

100

,000

Q1 - RichestNeighbourhoods

Q2

Q3

Q4

Q5 - PoorestNeighbourhoods

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

FoodI. 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

Welfare Assistance Situation for persons in Ontario, 2008 Single Person Considered

Employable

Single Personwith a Disability

Lone Parent with Child Aged Two

Couple with Two Children Aged 10 & 15

Total Income $7,352 $12,647 $16,683 $21,215

Benefits Decline

from 1992

$4,04836%

$3,06920%

$5,76112%$

$8,67429%

Source: National Council of Welfare (NCW) (2010). Welfare Incomes, Nos. 1-4. Ottawa: NCW

19

Figure 3.5: Total Average Income by Income Quintile, All Family Units, Canada, 1995-2008

15,00013,100

55,10047,500

169,000

128,400

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

Lowest Quintile Second Quintile Middle Quintile

Fourth Quintile Highest Quintile

Figure 5. Number of Canadians Assisted by Food Banks: 1989-2010 (March of Each Year)

0200,000400,000600,000800,000

1,000,000

89 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Year

Num

ber A

ssist

ed

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

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.

The Way Forward

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

28

29

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 Constitution 1867/1982

• “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…

33

34

35

36

thecanadianfacts.org

37

Dennis Raphael

draphael@yorku.ca

This presentation and other presentations and related papers are available at:

http://www.atkinson.yorku.ca/draphael

[go to the library there]