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
1
October 12, 2011
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
2
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.
3
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 4
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.
5
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)
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Social determinants of health
(SDH) are the primary factors
shaping health
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Diabetes prevalence by age and income
18.00%
16.00%
14.00%
Prevalence
12.00%
NO INCOME or < $29,999
10.00%
$30,000-$79,999
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
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Increased Risk of
Type 2 Diabetes
Figure 4. Increased Risk of Type 2 Diabetes for Lower Income
Men not Affected by Weight or Physical Activity
3
2.07
1.94
Income
<$15,000
Education,
Weight, and
Physical Activity
Taken into
Account
1.72
1.66
Income
$15,000-29,999
Education,
Weight, and
Physical Activity
Taken into
Account
2
1
0
Lower Income Groups
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
9
Increased Risk of Type 2
Diabetes
Figure 5. Increased Risk of Type 2 Diabetes for Lower Income
Women Slightly Affected by Weight and Physical Activity
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3.57
2.75
3
2.58
2.1
2
1
0
Income
<$15,000
Education,
Weight, and
Physical
Activity Taken
into Account
Income
$15,000-29,999
Education,
Weight, and
Physical
Activity Taken
into Account
Lower Income Groups
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
Increased Risk of Type 2
Diabetes
Figure 6. Increased Risk of Developing Type 2 Diabetes over a
two year Period for Canadians Living in Poverty
1.5
1.24
1.28
1.26
1.24
Living in
Poverty During
Period Prior to
Developing
Diabetes
Adjusted for
Obesity and
Physical
Inactivity
Living in
Poverty at Any
Time During
the Course of
the Study
Adjusted for
Obesity and
Physical
Activity
1
0.5
0
Poverty Situation
Dinca-Panaitescua, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and
Raphael, D. (2011). The dynamics of the relationship between poverty experience
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and type 2 diabetes: Longitudinal results. York University: SHPM.
SDH shape access to care,
management of illness, and
recovery from illness
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Mortality Rates Per 100,000
Figure 1. Diabetes Mortality, Urban Canada,
1971-2001, Males
Q1 - Richest
Neighbourhoods
25
Q2
20
15
Q3
10
Q4
5
Q5 - Poorest
Neighbourhoods
0
1971
1976
1981
1986
1991
1996
2001
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.
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Mortality Rates Per 100,000
Figure 2. Diabetes Mortality, Urban Canada,
1971-2001, Females
Q1 - Richest
Neighbourhoods
25
Q2
20
15
Q3
10
Q4
5
Q5 - Poorest
Neighbourhoods
0
1971
1976 1981
1986 1991 1996
2001
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.
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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.
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Food
72% of participants indicated that they lacked the
economic resources required to acquire the
kind of diet they knew they must follow.
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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]
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Social Assistance Levels do not Allow for Health
Welfare Assistance Situation for persons in Ontario, 2008
Single Person
Considered
Employable
Single Person
with 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
$4,048
36%
$3,069
20%
$5,761
12%$
$8,674
29%
Source: National Council of Welfare (NCW) (2010). Welfare Incomes, Nos. 1-4. Ottawa: NCW
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Figure 3.5: Total Average Income by Income
Quintile, All Family Units, Canada, 1995-2008
169,000
55,100
Lowest Quintile
Second Quintile
Fourth Quintile
Highest Quintile
08
20
07
20
06
20
05
22
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
15,000
19
96
19
19
95
180,000
160,000
128,400
140,000
120,000
100,000
80,000
60,000 47,500
40,000
20,000
0 13,100
Middle Quintile
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Number Assisted
Figure 5. Number of Canadians Assisted by Food Banks:
1989-2010 (March of Each Year)
1,000,000
800,000
600,000
400,000
200,000
0
89 97 98 99 00 01 02 03 04 05 06 07 08 09 10
Year
Source: Food Banks Canada (2011). Hunger Count. Toronto: Food Banks
Canada.
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.”
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Citizen involvement is a primary
means of influencing the quality
of the SDH and affecting health
and health care outcomes
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The Role of Public Health Units
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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.
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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.
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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 26
Health. Geneva: World Health Organization.
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
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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
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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
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Learn more…
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thecanadianfacts.org
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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]
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