Seeing beyond the formal health care
system … to produce and maintain health
Gloria DeSantis, PhD
Research Associate, SPHERU
February 3, 2012
Overview
1. What is SPHERU?
2. Seeing beyond ...
a) health & population health
b) social determinants of health
c) community-based organizations (CBOs)
3. Introduction of research project
4. Emphasis on methods and challenges faced
5. Summary and questions
What do we do at SPHERU?
Vision
Working with communities and policy makers to
improve the health of Saskatchewan people.
Mission
The promotion of health equity by understanding
and addressing population health disparities
through policy-relevant research.
Our Research
• examines intersectoral implications for
the implementation of population health
interventions
• contributes to knowledge translation
through the synthesis of theoretical and
methodological innovations
• applies novel approaches, research
designs, and frameworks in studies
• increases capacity of Saskatchewan
researchers, academics, community
partners and governments in research,
knowledge translation and policy
development and innovation
Research
Themes
History of Health Inequities
•
•
Northern & Aboriginal Health
•
•
explores the role of culture as a
determinant of health
develops culturally relevant definitions
of health and appropriate health
indicators
Healthy Children
•
Rural Health
•
•
explores rurality as a determinant of
health
involves local partners to address
inequities in health-determining
conditions
examines how health in Saskatchewan
has changed over the last century and
has varied among communities
provides lessons for modern policy
makers by understanding historical
health outcome disparities
creates understanding of how various
contexts – family, neighbourhood social
and physical environments, schools –
play a role in determining children’s
health and development
Intervention Research
•
•
promotes capacity by engaging in policy
and program evaluation
impacts policy by involving policy makers
and addressing specific health disparities
Knowledge Transfer and Exchange
• collaborative research projects
• research findings in plain
language (e.g., newsletters)
• videos
• toolkits of findings for
communities to use
• research networks for
knowledge exchange
• conferences and forums
• expert dialogues
Let us situate SPHERU’s work &
the current research project
This presentation offers a tiny glimpse
beyond this formal health system
• Historically, major advances in health status
resulted from broad social reforms in
communities (Hofrichter 2003; Green & Labonte 2008)
- Virchow’s work in 1847
• Most of what keeps us healthy lies outside the
formal health care system (Evans 2003; Lalonde 1974;
Marmor et al 1994; Orsini 2007)
A broad definition of health
“Health is a state of complete physical, social
and mental well-being and not merely the
absence of disease or infirmity …” (WHO 1998, p. 11)
- important to add “spiritual” as per Aboriginal
communities’ conceptualizations of health (Loppie
Reading 2009)
Defining population health
Determinants of
health
+
- sustainable ecosystems
- built environments
- community supports
- social equity e.g. poverty
- prosperity
- human biology
- personal health behaviour
- health services
Processesof-change over
the life course
Population
health
status:
- education, life long
learning
- governance
- positive
- negative
- disparities
(inequities)
(volunteerism,
engagement,
participation,
voter turnout, etc.)
(see also Hancock et al. 2000; SPHERU 2002)
More specifically,
social determinants of health are:
•
•
•
•
•
•
•
•
•
•
Socio-economic circumstances (e.g., income)
Stress
Early life
Social exclusion
All of these
Work
influence
Unemployment
health
Social support
Addiction
Food
Transport
(Wilkinson & Marmot 2003)
Research on social determinants shows:
• In general, some groups have worse health
status than others
– people who live in poverty
– many First Nations peoples
– many immigrants & refugees
– people with disabilities
– single moms with children … etc.
• This reveals inequities
So what is health equity?
Equity = fairness
Inequities are differences across groups which
are unfair, unnecessary, and avoidable (Edwards 2009)
Some groups of people
sleep here …
… while others
sleep here.
Groups who live, work and play in poor
social conditions, have poorer health
(Whitehall II Study, Wilkinson & Marmot 2003, WHO 2008)
• Dynamics of SDOH are complex
• Effects of SDOH mediated by other factors like
health care, air quality, etc. (Danaher 2011)
Also, beyond the formal health care
system are social service CBOs
• Health/well-being of communities depends on
variety actors in myriad environments (Bolen &
Ramsey 2007, Raphael 2004)
• Role for social service, community-based
organizations (CBOs) in facilitating
health/well-being (Bell 2009, Hall & Banting 2000, DeSantis
2008)
Social service CBOs defined
• institutionally separate from government and
the private sector
• have an organizational structure
• exist to serve a public benefit
• are self governing
• do not distribute profits to members and
• depend on volunteers to varying degrees
(Government of Canada, 2002; Hall & Banting, 2000)
Examples of social service CBOs
Indian Metis Christian Fellowship
Social service CBO functions in society
(Danaher 2011, DeSantis 2008)
• Provide programs & services
• Engage their communities, build capacity, trust, etc
• Advocate for healthier public policy at multiple
levels
• Inspire innovative approaches
• Encourage cross-sectoral collaboration & work
across government silos
Support, defend and offer a safety net for the most vulnerable
Quick check-in regarding where we’ve
just come from
• Defined health & population health
• Defined social determinants of health (SDOH)
• Defined social service, community-based
organizations (CBOs)
Now let us consider the specifics of a
SPHERU research project:
Seeing beyond the formal health care
system … to produce health
with emphasis on the methods, not results
Introduction to the project
• Regina Regional Intersectoral Committee (RIC)
recognized importance of SDOH
• RIC Community Support Team decided to
survey Regina organizations, conducted the
survey (2009)
- CBOs, quasi-government, governments
- this presentation focuses on CBO data only
• SPHERU became involved in data analysis phase
Research project objectives
a) To document SDOH* in Regina organizations
b) To raise awareness of SDOH among
organizations
c) To use collected data to facilitate more
integrative & collective action
d) To create a publicly accessible inventory
* RIC used the term “determinants of community wellbeing” (DCWB) instead of SDOH
Method of data collection - overview
• Semi-structured survey research
- qualitative & quantitative elements
• Convenience sample using RIC member e-lists
(N=169)
- easy access for participants
• On-line survey using “Survey Monkey”
- free, easy to create, easy for respondents
Method of data collection - sample
What organizations comprise the sample?
• 37 CBOs reported on 77 initiatives (22% response
rate)
• 75% offer services at city scale
• Almost equal split between agencies operating on
– < $100,000/year,
– $100,000 to $499,999/year,
– >$500,000/year
• 70% agencies had < 25 staff
Method of data collection - survey
On-line survey:
• 5 organization questions - mandate, #
employees, geographic focus, annual
operating budget, sources of funding
• 12 questions about DCWB initiatives –
mandate, target populations, partners, key
activities, funding amount and sources, DCWB
priority areas …
• No confidentiality or anonymity issues
Method of data collection - survey
Example
questions
Method of data collection - survey
Example
questions
Method of data collection - survey
Example questions
Note: determinants of community well-being = determinants of health
Method of data analysis
Primary method used was content analysis:
• Data cleaning
• Frequency counts, percentages, “sort”
function using excel
- bar graphs
- diagramming and mapping
• Summarization
• Explication
Methods – some challenges
At times we wanted to pretend the data had
never been collected:
1. Sample and universe – generalizability?
2. Respondents – front-line versus managers
3. Survey questions
- mutually exclusive categories?
- on-line thus no opportunity to clarify
- check boxes versus open questions
4. “Survey Monkey” data stored in American co.
Results - spatial distribution of sample
Results – determinants of community
well-being (or SDOH)
Results - activities offered by 77 initiatives
Results – sources of funding
Results – amount of funding
• 44% (N=34) initiatives had annual operating
budget < $50,000
- one funding source was most common
- donations & fundraising most common
• 31% (N=24) initiatives had annual operating
budgets > $200,000
- two or three funding sources most common
- donations, fundraising & provincial funding
common
Results – service partnerships
Summary and lingering questions
1. CBOs are working on variety of SDOH
- social inclusion & social safety net most common
- most frequently cited activities were social
supports, community engagement & education
- focus on “discriminated” groups
BUT, what are actual impacts?
2. Income and its inequitable distribution least cited
SDOH
Poverty exists in Saskatchewan, but there’s no
provincial strategy for its elimination?
Summary & lingering questions
3. a) SDOH initiatives funded most frequently by
donations and fundraising/earned income
b) largest number had very small budgets
Are we as a society comfortable with acts of
charity as part of a SDOH funding model?
4. In general, CBOs had multiple partners, thus a
degree of service integration exposed
BUT is this enough to meet the goal of crosssectoral, collaborative, integrated planning
required to reduce health inequities?
In closing ...
• Communities are central
places for health production
and maintenance; there is
plenty of evidence.
• This research begs many
more questions … let us see
beyond the formal health
care system to work toward
policy and program answers
(see SPHERU Lancet article
for a start)!
Acknowledgements
• the people with whom I work and volunteer who are
committed to changing social and health inequities
through CBOs … they keep me going!
• colleagues Carla Bolen (formerly RQHR) & Wendy Stone
(Regina Police Service), my research partners
• SPHERU colleagues
• Fellowship funding from Saskatchewan Health Research
Foundation
THANK YOU FOR LISTENING - I LOOK FORWARD TO YOUR QUESTIONS!