A Framework to Integrate Social and Economic Determinants of

Transcription

A Framework to Integrate Social and
Economic Determinants of Health into
the Ontario Public Health Mandate:
A Discussion Paper
A report from the Sudbury & District Health Unit
March 2006
Stephanie Lefebvre, MSW, Health Promoter
Claire Warren, MN, Community Nurse Specialist
Sandra Laclé, MScN, Director, Health Promotion
Dr. Penny Sutcliffe, Medical Officer of Health
This vision for public health, one that addresses the social and economic causes of health
disparities, is grounded in the work of hundreds of public health leaders from across the
province. The Sudbury & District Health Unit hosted a determinants of health stream as part of
the November 2005 Joint Conference of the Association of Local Public Health Agencies
(alPHa) and Ontario Public Health Association (OPHA), Determinants of Health: Developing an
Action Plan for Public Health. This event was oversubscribed and brought together over 100
Ontario public health representatives to share their experiences and guidance for the
development of a social and economic determinants of health framework for the public health
mandate. This input, as well as the many efforts currently underway by local boards of health
and their communities have formed the foundation for the recommendations that follow.
For this framework to be effectively translated into practice, it must reflect the diversity of
Ontario’s local health units and acknowledge the contributions of players outside of the health
unit system. The recommendations of this report have benefited from the input of a reference
panel with membership representing a broad cross-section of public health perspectives. We
are indebted to the following reference panel members for their thoughtful comments:
Connie Clement, Executive Director, Ontario Prevention Clearinghouse (OPC)
Vera Etches, Associate Medical Officer of Health, Sudbury & District Health Unit
Charles Gardner, Medical Officer of Health, Simcoe Muskoka District Health Unit
Beth Henning, Medical Officer of Health, Huron County Health Unit
Hanif Kassam, Medical Officer of Health, Regional Municipality of Peel Health Department
Maureen McKeen, Director, Peterborough County Health Unit
Isabelle Michel, Director, Resources, Research, Evaluation and Development, Sudbury &
District Health Unit
Allan Northan, Medical Officer of Health, Algoma Health Unit
Rosana Pellizzari, Medical Officer of Health, Perth District Health Unit
Pete Sarsfield, Medical Officer of Health, Northwestern Health Unit
Theresa Schumilas, Director, Health Determinants, Planning & Evaluation, Region of Waterloo
Public Health
Linda Stewart, Executive Director, Association of Local Public Health Agencies (alPHa)
Lisa Sullivan, Manager, Research and Policy Analysis, Canadian Population Health
Initiative, Canadian Institute for Health Information (CIHI)
Connie Utrecht, President, Ontario Public Health Association (OPHA)
Lastly, this project would not have been possible without the support of our project funder, the
Public Health Agency of Canada, and sponsoring agency, the Ontario Prevention
Clearinghouse. Their financial support, leadership and encouragement have been instrumental
to the advancement of a social and economic determinants of health mandate for public health
in Ontario.
Claire Warren, BScN, MN
Community Nurse Specialist, Manager Professional Practice & Development
Resources, Research, Evaluation and Development Division
Public Health Research, Education and Development (PHRED) Program
Sudbury & District Health Unit
1300 Paris Street
Sudbury, ON P3E 3A3
(705) 522-9200, ext. 239
Email: [email protected]
The opinions expressed in this publication are those of the authors and do not necessarily
reflect the view of the Public Health Agency of Canada or any other organization or individual
contributing to the development of this publication.
Lefebvre, S., Warren, C., Laclé, S., & Sutcliffe, P. (2006). A framework to integrate social and
economic determinants of health into the Ontario public health mandate: A discussion paper.
Sudbury, Ontario: Sudbury & District Health Unit.
Executive Summary .....................................................................................................................i
Introduction ................................................................................................................................ 1
Discussion Outline ..................................................................................................................... 3
Need: How big is the problem? ................................................................................................. 4
Appropriateness: Are we the best people to do it? .................................................................... 8
Proposed Frameworks ..........................................................................................................10
Impact: How much can we fix it? ..............................................................................................14
Capacity: Are we able to do it?..................................................................................................25
Key Public Health Initiatives ..................................................................................................25
Challenges ............................................................................................................................26
Recommendations and Necessary Next Steps .........................................................................27
References ...............................................................................................................................29
Appendices ...............................................................................................................................33
Appendix A
Draft Proposed General and Program Standards for the Social
Determinants of Health...............................................................................35
Appendix B
The Population Health Template Working Tool ..........................................41
Appendix C
Health Goals for Canada............................................................................43
Figure 1: CIHR-IPPH Conceptual Framework of Population Health .........................................11
Figure 2: The Population Health Promotion Model ...................................................................12
Figure 3: Healthy Communities/Indicators Model .....................................................................13
Table 1: Literature Support for Action on Social and Economic Determinants of Health............ 5
Table 2: Public Health Goals, Activities and Indicators to Measure Progress Related to the
Social and Economic Determinants of Health .............................................................18
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“Health disparities are the number one health problem in the country and health care
alone is powerless to overcome them (Health Council of Canada, 2005, p 9).”
It is widely recognized that population health status will significantly improve only if there is an
invigorated and coordinated approach to address the social and economic determinants of health
and reduce growing health disparities. Ontario’s public health system is well poised to take
concerted action in this area. The provincial government is engaged in a public health renewal
agenda under Operation Health Protection: An action plan to prevent threats to our health and to
promote a healthy Ontario (Ministry of Health and Long-Term Care, 2004), including an announced
review of the mandate of provincial public health units. Staff in public health units have
demonstrated a capacity and desire for action in this area. The timing is right for the uptake of
innovative initiatives that will further the public’s health.
The current formal mandate for the Ontario public health system does not include specific program
requirements to either mitigate or address underlying social and economic risks to health. If public
health is to be successful in improving and protecting the health of the population, social and
economic conditions must be a key domain of public health action.
In follow up to Board of Health interest in this area, the Sudbury & District Health Unit (SDHU)
hosted a determinants of health stream as part of the November 2005 Joint Conference of the
Association of Local Public Health Agencies (alPHa) and Ontario Public Health Association
(OPHA), Determinants of Health: Developing an Action Plan for Public Health. This event was
oversubscribed and brought together over 100 Ontario public health representatives to share their
experiences and guidance for the development of a social and economic determinants of health
framework for the public health mandate. Additionally, motions supporting a social and economic
determinants of health public health mandate were sponsored and carried at the respective 2005
Annual General Meetings of the alPHa and OPHA.
Building on the work and momentum of the conference, the SDHU benefited from a small grant to
draft this more detailed discussion paper. The recommendations of this paper are informed by the
input of a reference panel with membership representing a broad cross-section of public health
perspectives. In addition, they are congruent with current provincial government priorities.
Principles for Setting Strategic Directions of Public Health
The formal mandate for the Ontario public health system is incorporated into the Mandatory Health
Programs and Services Guidelines (MHPSG). The MHPSG incorporates a methodology for setting
strategic priorities and standards for public health and establishes decision-making criteria. These
criteria are:
Need: How big is the problem?
Appropriateness: Are we the best people to do it?
Impact: How much can we fix it?
Capacity: Are we able to do it? (MHPSG, 1997)
Public Health SDOH Framework: A Discussion Paper
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This discussion paper builds an argument for the public health mandate that includes the social and
economic determinants of health based on the current MHPSG criteria.
Recommendations and Necessary Next Steps
The following recommendations are made for the successful incorporation of social and economic
determinants of health into the formal Ontario public health mandate:
1. That a general and a program standard related to the social and economic determinants
of health be incorporated in the revisions to the Mandatory Health Programs and Services
Guidelines (MHPSG).
2. That the models and frameworks presented in this paper be adopted within the new
MHPSG.
3. That an interministerial committee be assembled as soon as possible with key inservices
related to the health impact of social and economic conditions and opportunities for policy
recommendations and implementation.
Furthermore, the discussion paper demonstrates that public health is positioned to take the lead
and can make significant gains in improving health status. The following next steps are
recommended in order to achieve an effective and efficient transition to incorporating social and
economic determinants of health into public health:
4.
Consultation – Further consultation with key community and public health stakeholders
is necessary in order to refine the social and economic program standards, indicators
and specific public health activities and targets.
5.
Research and knowledge exchange – Further to recommendations of the Agency
Implementation Task Force (2006), the development of a province-wide network for
public health research, training and knowledge exchange must support an agenda that
includes research and tool development relating to the social and economic
determinants of health.
6.
Healthy public policy assessment and advocacy – Formal, interministerial structures are
necessary in order to effectively conduct health impact assessments related to new and
existing public policies, especially as it relates to the social and economic determinants
of health. As the health of populations is impacted by the mandates of a variety of
provincial ministries, collaboration between ministries is essential to the establishment
of healthy communities and public policies.
7.
Public health capacity building – The introduction of a mandate that incorporates social
and economic determinants of health will necessitate training of and capacity building
for local boards of health and public health staff. A province-wide network for public
health research, training and knowledge exchange (Agency Implementation Task
Force, 2006), must support training related to the social and economic determinants of
health as well as the local conduct of health impact assessments.
With these recommendations in place, an exciting phase begins – one that redefines the role of
public health in Ontario. A shift in the focus of public health activities toward the social and
economic determinants of health has great potential to improve opportunities for health for all
Ontarians.
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Evidence is widespread, solid and increasing that social and economic determinants of health
have a significant impact on population and personal health (Canadian Public Health
Association, 1997; World Health Organization; 1998; Canadian Population Health Initiative,
2004). To excerpt from a report by the Ontario Prevention Clearinghouse (OPC),
“Provision of quality health care, while very important, is only one factor of many that
contribute to a population’s health. The general public defines only a small number
of key factors as generating good – and bad – health: availability of health care
services; good genes (or good luck); and personal choices regarding behaviours
such as eating and exercise. Few Canadians identify poverty, housing or
environment as important causes of health status. Yet current evidence suggests
that while access to health services, genetics and personal behaviours are very
important to health outcomes, they aren’t as influential as societal and biological
factors when considering overall health status and chronic disease conditions.
By observing the health of large groups of people, researchers have come to
understand the remarkable sensitivity of health to the social and built environments.
They have identified powerful determinants of health in modern societies. These
determinants of health include: income and social status; social supports; education
and literacy; employment and working conditions; social environments such as
housing; physical environments (air, soil, water); healthy child development; gender;
culture; biology and genetic endowment; personal health practices and coping skills;
and health services (2006, p. 4).”
Unfortunately, however, the attributable risk of social and economic conditions to health status
is largely not addressed by Ontario’s formal public health system. The current mandate for
Ontario’s 36 public health units includes a general requirement to ensure equal access to public
health programs. The mandate, however, does not include specific program requirements to
either mitigate or address underlying social and economic risks to health. From a historical as
well as social justice perspective, public health has an ethical obligation to: assure the
conditions for the population’s health, acknowledge social and economic conditions as vital
causes of morbidity and premature mortality, and address the fundamental determinants of ill
health (Gostin, 2001). With these obligations in mind, public health can begin to “lay plans for a
new public entitlement – the right to full and equal protection for all persons against preventable
disease and disability” (Beauchamp, 1976, p. 7).
Many efforts to improve the social and economic conditions that impact health are supported by
current Provincial government priorities – success for students; better health; and strong people,
strong economy. Included in their 2005 progress report, Working together for a better Ontario
(2005), are initiatives that provide for accessible early learning and child care spaces, support
for post-secondary education, apprenticeship opportunities and enhanced literacy, improved
access to health care and support for new immigrants. These, as well as other key government
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priorities, can be advanced with the explicit support and action of the public health sector. Of
note is that other jurisdictions have taken decisive health sector action on social and economic
determinants of health. These will be highlighted in this paper and have the potential to be
transferable to Ontario’s public health system.
In addition to the abovementioned key priorities, Ontario’s public health system is at a
crossroads with the current renewal agenda under the provincial government’s action plan,
Operation Health Protection: An action plan to prevent threats to our health and to promote a
healthy Ontario (MOHLTC, 2004). The timing is right for the uptake of innovative initiatives that
will further the public’s health. In fall 2005, Ontario moved closer to a defined and required role
for public health units to address social and economic determinants of health. The first annual
Joint Conference of the Association of Local Public Health Agencies (alPHa) and the Ontario
Public Health Association (OPHA) was held in November, 2005. A major initiative of the
conference was a social and economic determinants of health stream, led by the Sudbury &
District Health Unit (SDHU). Over the course of five working sessions, participants shared their
experiences, provided recommendations, and drafted a framework for a provincial
“determinants of health mandate” (see Appendix A for a summary of conference
recommendations). These recommendations included the following:
The revitalized public health system in Ontario must have a clearly articulated role in
working to address the underlying social and economic factors that determine health;
The social determinants of health need to be included within Ontario’s Mandatory Programs
and Services Guidelines as both a General Standard (applied across public health
programs), as well as a specific Program Standard;
A “Social Determinants of Health” Program Standard would address objectives including:
income and income distribution; education; employment; housing; social inclusion; and food
security. Community capacity and partnerships, access to services, research, and mental
health promotion, were also identified as key action areas to be considered in the
development and implementation of new mandate for public health.
Motions were passed at each of the annual general meetings of alPHa and OPHA relating to the
importance of the social and economic determinants of health and the need to develop a social
and economic determinants of health framework for public health in Ontario. The conference
concluded with participant recommendations being presented to the closing panel, “Moving
Towards Action”.
Dr. Sheela Basrur, Ontario’s Chief Medical Officer of Health, Dr. David
Butler-Jones, Canada’s Chief Public Health Officer, and Dr. Geoff Dunkley, Co-Chair of the
Agency Implementation Task Force all responded enthusiastically to the stream’s
recommendations and supported collaboration between initiatives of all levels of government as
public health moves forward on a revised mandate that includes social and economic
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“Health disparities are the number one health problem in the country and health care alone is
powerless to overcome them” (Health Council of Canada, 2005, p. 9). This acknowledgement
by the Health Council of Canada highlights the need for a new, coordinated approach to
addressing the social and economic determinants of health. Ontario’s existing Mandatory
Health Programs and Services Guidelines (MHPSG) provides a methodology for setting
strategic priorities and standards for public health and establishes decision-making criteria
based on need, appropriateness, impact and capacity (MHPSG, 1997). These four key
principles provide an effective outline for the following recommendations and framework for the
integration of social and economic determinants of health within Ontario’s public health
mandate. Section summaries are as follows:
Need: How big is the problem? In the context of assessing the health needs of
populations, this section will highlight key findings related to the health impact of social and
economic determinants of health.
Appropriateness: Are we the best people to do it? A common challenge to addressing
the health impact of social and economic determinants lies in the fact that they are
frequently rooted outside of the traditional sphere of public health. Income, education and
employment, for example, whilst among the key determinants of health, are shaped by the
diverse policies, and politics, of a variety of community and government sectors. With this in
mind, this section will highlight how Ontario’s public health practitioners are uniquely poised
to address the social and economic determinants of health. It will also recommend a
framework for action that outlines public health’s specific role within an intersectoral
approach to improving population health.
Impact: How much can we fix it? If public health is to successfully carry out activities
aimed at improving the social and economic conditions that foster health, it will be
necessary to establish measurable goals and objectives related to those conditions.
Drawing from other jurisdictions, as well as relevant work at the provincial and national
levels, this section will propose appropriate public health actions and indicators by which to
measure progress on the social and economic determinants of health. Furthermore, it will
discuss several opportunities, as well as limitations, related to the measurement of the
health impact of social and economic factors.
Capacity: Are we able to do it? The implementation of the following framework to integrate
social and economic determinants of health into Ontario’s public health mandate will depend
on support from all levels of government and community sectors, as well as the coordinated
activities of a diverse public health staff. Recommended next steps will outline the process
required to disseminate the proposed social and economic determinants framework as well
as achieve the commitment of varied public health and community stakeholders.
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This MHPSG priority-setting criterion is based on the foundation that, “Understanding the
determinants of health – social, economic, behavioural, educational, biological, genetic, the
physical environment and the workplace – is an important component of assessing need”
(MHPSG, 1997, p. 4). As public health practitioners, it is our role not only to assess health
needs based on traditional markers of disease morbidity and mortality, but also to assess the
root causes of health outcomes. In the case of the social and economic determinants of health,
an ever-growing and respected body of literature demonstrates a strong relationship between
our social environment and the health of our communities - a relationship that has been
observed as far back as the mid-19th century. In the early 1840s the British Royal Commission
on the Health of Towns highlighted the need to improve the unsanitary living conditions of
Britain’s poorest communities. As early as 1843, an editorial published in the Lancet
demonstrated wide disparities in life expectancy between different towns and rural areas.
Gentry and professionals living in the city of Bath experienced an average life expectancy of 52
years. In comparison, the average life expectancy of labourers living in Liverpool or Manchester
ranged between 15 and 17 years (Whitehead, 1997). Subsequent seminal research, such as
that of Marmot et al. (Whitehall Studies), Wilkinson (health impact of inequalities) and Hertzman
(social inclusion and early childhood development) provides a strong foundation for action. It
sheds light not only on the conditions associated with health disparities, but also on the complex
interactions between determinants of health. Public health is ready, and required, to apply this
evidence to practice.
As previously noted, recommendations from the determinants of health stream of the 2005 Joint
Conference of the Association of Local Public Health Agencies (alPHa) and the Ontario Public
Health Association (OPHA) call for public health action on six key social and economic
determinants: income and income distribution; education; employment; housing; social
inclusion; and food security. These recommendations are informed by the experiences of public
health practitioners and supported by a volume of Canadian and international research. It is not
possible to do justice to the wealth of academic and qualitative, community-level data which
support the health impact of social and economic determinants of health. However, for the
purposes of this discussion paper, a small sample of this literature support is presented as
Table 1. The selected examples relate specifically to the social and economic determinants
action areas identified by alPHa/OPHA conference participants and are meant to provide a
foundation on which to build recommendations for future public health action.
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(Health Canada, 1999)
“Canadians with low literacy skills are more likely to be unemployed and poor, to suffer
poorer health and to die earlier than Canadians with high levels of literacy.”
Low literacy levels have been associated with the following determinants of health: living
and working conditions; personal health practices and coping skills; physical environment;
health services; biology; and genetic endowment.
Compared to non-graduates, high school graduates: use preventative medical services
11% more frequently; make 2% fewer multiple visits to doctors; have 23% better knowledge
of health behaviours; and have 13% better general health status.
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(Wilkinson, 1996)
Repeatedly, research demonstrates that countries in which, “the income differences
between rich and poor are larger (meaning more or deeper relative poverty) tend to have
worse health than countries in which the differences are smaller.” The most egalitarian
societies (not the richest) demonstrate the best health.
(Ungerlieder & Keating,
2002)
(Raphael, 2003)
Research investigating health disparities between countries demonstrates that those with
highest rankings on selected social and economic determinants of health also rank highest
on traditional indicators of health status.
“In the 1996-97 National Population Health Survey (NPHS), only 19% of respondents with
less than a high school education rated their health as "excellent" compared with 30% of
university graduates.”
(Benzeval & Judge, 2001)
A 2001 review of 16 studies, using 8 different data sets and representing four different
countries concluded that, “All of the studies that include measures of income level find that
it is significantly related to health outcomes.”
Source
(Public Health Agency of
Canada)
Selected Literature Support
“Health status improves at each step up the income and social hierarchy. High income
determines living conditions such as safe housing and ability to buy sufficient good food.
The healthiest populations are those in societies which are prosperous and have an
equitable distribution of wealth.”
Education
Income and Income
Distribution
Social
Determinant
Action Area
Table 1: Literature Support for Action on Social and Economic Determinants of Health
Table 1: Literature Support for Action on Social and Economic Determinants of Health (continued)
Social
Determinant
Action Area
Employment
Unemployment and economic instability have been shown to be associated with significant
mental health problems and negative physical health outcomes both for individuals, their
families and communities.
Studies of deaths due to coronary heart disease have demonstrated that, “the higher the
occupational level, the lower the mortality rate.”
(Marmot et al., 1978)
“Precarious employment is a source of stress due to a lack of income and meaningful work,
uncertain prospects for the future, and its potential to undermine social support networks.”
Housing
Social Inclusion
Source
(Tremblay, 2002)
Literature has demonstrated the following: homeless individuals have poor access to health
care; poor housing conditions are associated with adverse physical and mental health
outcomes; and stresses linked with unaffordable and/or inadequate housing can have a
negative impact on health status.
(Bryant, 2004)
“Housing, as a central locus of everyday life patterns, is likely to be a crucial component in
the ways in which socio-economic factors shape health.” Material, meaningful, and spatial
dimensions have been identified as mechanisms through which housing conditions impact
health status.
(Dunn, 2002)
Social inclusion is often indicated through other measures of social and economic wellbeing. Poverty, racism, lack of educational and employment opportunities, poor housing
conditions, can all serve to exclude individuals from meaningful participation in community
life.
(Laidlaw Foundation,
2002)
“In addition to the negative health effects of relative deprivation, the actual experience of
inequality and the stress associated with dealing with exclusion tend to have pronounced
psychological effects and to impact negatively on health status.”
(Kawachi et al., 1999)
“Optimum environments for children have six basic characteristics: they encourage
exploration; provide mentoring in basic skills; celebrate the developmental advances of
children; encourage children to develop the aptitudes they spontaneously declare to the
outside world; provide protection from inappropriate teasing or punishment; and provide a
rich and responsive language environment. Social exclusion, such as that frequently
influenced by low socioeconomic status, acts as a barrier to healthy child development.”
(Hertzman, 2002)
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Table 1: Literature Support for Action on Social and Economic Determinants of Health (continued)
Social
Determinant
Action Area
Food Security
Source
“Some 10% of Canadian households, representing 3 million people, experience food
insecurity each year. Prevalence is greatest among those who rely on social assistance,
lone mothers with children, Aboriginal people and Canadians who live in remote
communities. Food insecurity is associated with increased odds of poor or fair self-rated
health, multiple chronic conditions, distress and depression.”
(Health Disparities Task
Group, 2004)
Canadian household food expenditure data suggests that low income is a barrier to
purchasing milk products and fruits and vegetables.
(Tarasuk, 2004)
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Health promotion and population health research have assisted us in recognizing that the major
determinants of health lie beyond health care, in the broader social, economic, environmental,
political and cultural factors that shape our lives as individuals, communities and societies.
Nevertheless, there have been many critical documents and initiatives, at the federal, provincial
and local levels that strongly support health sector involvement in tackling health inequities. The
following examples are meant to provide an overview of the knowledge, recommendations and
commitments previously demonstrated by Canadian governments.
It was the 1974 report by Canada’s Minister of Health and Welfare, Marc Lalonde, that first
began a shift in the way Canadian policy-makers viewed health and wellness. “A new
perspective on the health of Canadians”, acknowledged the impact of biological, behavioural
and health care system influences on health, however also recognized our social environment
as a determinant of health. This paper set the stage for the population health perspective that is
applied across public health activities. In 1994, the Federal/Provincial/Territorial Advisory
Committee on Population Health presented a paper on strategies for population health to the
Ministers of Health. It recommended the need to strengthen public understanding about the
broad determinants of health, to enhance public support for and involvement in actions to
improve the health of the overall population and to reduce health disparities experienced by
some groups of Canadians (Health Canada, 1994). Recently, much has been done to further
support these recommendations.
Although certainly not an exhaustive list, the following
provides a chronicle of several key federal level initiatives related to the social and economic
2002 – Romanow Commission report discusses the importance of addressing disparities in
order to sustain our current health care system (Commission on the future of health care in
Canada, 2002).
2003 – First Ministers’ Health Accords makes national commitments to reducing health
disparities (Health Canada, 2003).
January 2005 – Health Council of Canada delivers 2004 inaugural report identifying priority
areas for action. Priorities include a broad intersectoral approach focusing on health
disparities - this was reiterated in their 2005 annual report (Health Council of Canada, 2005;
Health Council of Canada, 2006).
October 2005 – Integrated Pan-Canadian Healthy Living Strategy is approved by Federal,
Provincial and Territorial Ministers of Health. Based on a population health approach, it
envisions a healthy nation in which all Canadians experience the conditions that support the
attainment of good health by improving overall health outcomes and reducing health
disparities (Secretariat for the Intersectoral Healthy Living Network, 2005).
November 2005 – Announcement of the Health Goals for Canada: A federal, provincial and
territorial commitment to Canadians. One overarching goal and nine health goals have been
articulated including the need to respond to health disparities (Public Health Agency of
Canada, 2005).
This paper has referred to several important social and economic determinants initiatives taking
place at the provincial level. The recent conference stream of the 2005 alPHa/OPHA
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conference is one example of leadership in this area. Public health leaders from across the
province shared their experiences and priorities for addressing social and economic
determinants of health. The subsequent recommendations and resolutions adopted by both
OPHA and alPHa, further support the need to address the determinants of health within the
public health system. In addition, the Ontario Prevention Clearinghouse (OPC) is a strong
supporter of public health and partner in tackling health inequities and the broader determinants
of health. This is especially apparent from their 2006 conference “Moving Upstream Together.”
Key strategic partnerships, such as those fostered at this event, will be required in order for
public health to mobilize for action on the social and economic determinants of health.
Furthering federal and provincial support for action on the social and economic determinants of
health, there are numerous promising initiatives that have been undertaken by local public
health agencies, in partnership with municipal governments and communities. Several boards
of health have begun to include social and economic determinants of health in their strategic
plans. Region of Waterloo Public Health provides an example of effective integration of social
and economic determinants of health within the organizational structure of the health unit.
However, even without formalized structures in place, many boards of health have begun to
address the underlying causes of ill health. These initiatives take three forms. Each is
described below; however specific examples of local action are also highlighted in text boxes
throughout this paper.
1. Increased access to mandated public health activities. The Mandatory Programs and
Services Guidelines General Standard for Equal Access mandates local boards of health to
evaluate and address barriers to accessing all public health programs and activities. Programs
that consider the impact of social and economic factors may provide for childcare, travel
expenses, diverse literacy levels, languages, and
schedules for example. Many prenatal and early
Lanark, Leeds and Grenville
parenting programs provide positive examples of
Health Forum
these types of access initiatives.
2. Targeted public health interventions towards
disadvantaged populations. In order to reduce
health disparities across populations it is necessary to
assess and address the specific needs of
disadvantaged populations and implement strategies
to meet those needs (Health Disparities Task Group,
2004). As examples, public health programs aimed at
improving health behaviours, e.g. increased physical
activity or consumption of vegetables and fruits may
specifically focus on reaching low-income populations,
individuals with low levels of literacy, or of diverse
cultural backgrounds.
These targeted activities
acknowledge the resources, social support and
environmental conditions that impact behaviour
change.
3. Actions to address the root social and
economic determinants of health. Increasingly,
local boards of health are partnering with community
groups and individuals from all sectors to: a) identify
specific health needs related to the social and
As part of this forum, the Leeds,
Grenville and Lanark District Health
Unit worked in partnership with 80
other community agencies to evaluate
local determinants of health and
identify and implement activities within
an overall Health Improvement Plan.
Activities focussed around the
social and economic determinants of
health, and access to health care and
included advocacy efforts opposing
the provincial “clawback” of the
National Child Benefit Allowance and
a federal bill that would restrict the
eligibility criteria for disability
pensions.
Their experience demonstrates
that with sustained investment of
resources, a multistakeholder
approach to addressing social and
economic determinants of health is
both possible and promising (Gardner
et al., 2005).
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economic determinants of health; and b) develop and implement multisectoral responses to
those needs. Boards of health have effectively lent their voice to advocacy initiatives, partnered
to provide programs aimed at improving social and economic conditions, and participated in
research initiatives in order to better understand what is needed, and what works to improve the
physical and social health of their communities.
Although each of these types of initiatives represent promising opportunities for improved health
outcomes, an explicit mandate for action on the social and economic determinants of health is
needed. A mandate that acknowledges the significant impact of these determinants gives
validity to action both within public health and to the community at large. Mandated action
requires a shift in some of the prevailing thinking about health. It requires people to realize that
the health system has an important, but limited role in addressing health. It requires people to
challenge some of the ideas and values they may have about poverty, equity and social justice.
These are not individual issues, but structural ones. Due to the complexity of interactions
between the social and economic determinants of health, and in order to strive for the most
effective programs and services, it is imperative that public health foster partnerships that
address the economic, community and environmental characteristics that affect uptake across a
diverse range of life circumstances (Health Disparities Task Group, 2004).
As outlined above, public health is a shared responsibility with shared accountabilities. The
population health approach, which emerged in Canada in the 1990’s, addresses “the health
outcomes of a group of individuals, including the distribution of such outcomes within the group”
(Kindig & Stoddart, 2003). Given the complexity of approaches required to ensure public health,
it is important that action is based on a common understanding of relevant frameworks. This
paper proposes three frameworks to guide the different components of public health action on
the social and economic determinants of health. Figure 1, The Canadian Institute for Health
Research Conceptual Framework of Population Health (Frank, 2005), shapes our
understanding of the mechanisms through which various factors influence health outcomes.
Hamilton & Bhatti’s Population Health Promotion Model, (1996), Figure 2, highlights the
comprehensive approach required to affect positive change in the health status of populations.
Lastly, Figure 3, The Healthy Communities/Indicators Model, (Hancock, Labonté & Edwards,
2000), recommends a framework for establishing appropriate indicators with which to measure
progress on social and economic determinants of health. Each of these will now be elaborated
on with respect to recommendations for the inclusion of social and economic determinants of
health into Ontario’s public health mandate.
The Conceptual Framework for Population Health, (Figure 1), is a synthesis of the broad
determinants of both population and individual health. This model highlights the complexity of
factors and interactions that determine health. It identifies the dynamic effect of both upstream
forces (social, economic, cultural, political, etc.) as well as proximal causes (physical and social
environments, biological factors, genetic endowment) on the health of individuals, families,
communities, and societies. Furthermore, it recognizes the potential health disparities
experienced by different populations. For example, race, ethnicity, gender and socioeconomic
status all interact with proximal and upstream forces to determine health outcomes. For the
purposes of this discussion paper, this conceptual framework for understanding population
health provides an excellent foundation on which to build strategies for action.
10
Figure 1: CIHR-IPPH Conceptual Framework of Population Health
Frank, J. (2005). Conceptual Framework of Population Health. Ottawa: Canadian Institutes of Health Research –
Institute for Population & Public Health.
The Integrated Model of Population Health and Health Promotion, was a paper published in
1996 by the Health Promotion and Programs Branch (now known as the Public Health Agency
of Canada) to examine the relationship between population health and health promotion. As a
result of this initiative, a new model called The Population Health Promotion Model (PHP)
explains this relationship (Figure 2). It demonstrates how a population health approach can be
implemented through action on the full range of health determinants by means of health
promotion strategies as outlined in the 1986 Ottawa Charter. The PHP model draws on a
population health approach by showing that, in order to improve the health of the people, action
must be taken on the full range of health determinants. It reflects health promotion theory by
showing that comprehensive action strategies are needed to influence the underlying factors
and conditions that determine health. Furthermore, it reinforces that all actions and conditions
occur within the context of prevailing societal and structural values and assumptions. Reflection
on, and awareness of values is particularly relevant to work related to the social and economic
Tools such as The Population Health Template (Health Canada, 2001) have been developed in
order to facilitate the implementation of a population health approach (see Appendix B). The
template outlines key elements of population health including the need to address the
determinants of health and their interactions, increase upstream investments, apply multiple
strategies, and collaborate across sectors and levels. With both population health theory and a
tangible template for action in place, it is recommended that the integrated model of population
health and health promotion provides an excellent framework to help guide specific public health
action on the determinants of health while allowing regional flexibility in its application to best
meet the unique needs of each community.
11
Figure 2: The Population Health Promotion Model
Hamilton, N. & Bhatti, T. (1996). Population Health Promotion: An integrated model of population health and health
promotion. Health Promotion Development Division, Ottawa: Ontario.
A strategic priority, as outlined in Operation Health Protection, is the renewal of public health,
including: rebuilding public health capacity within the province; enhancing public health
leadership and accountability; and improving system collaboration and partnerships among
public health and other parts of the health system. Enhancing accountability requires the
development of measurable indicators. A key conceptual issue in indicator development is the
framework that is used to understand the domains. The Healthy Communities/Indicators Model,
(Figure 3), establishes three spheres (environment, economy, and community) involved in the
health of communities. Health lies at the intersection of these spheres. This model has been
proven to be both empirically useful and conceptually strong (Hancock, Labonté & Edwards,
2000).
Furthermore, the previously recommended action areas, (income and income
distribution, education, employment, social inclusion, housing, and food security), as well as the
indicators that will be proposed in the next section of this paper, can be located at the
intersection of the community and economy spheres – where equitable communities are
established.
12
Figure 3: Healthy Communities/Indicators Model
Hancock, T., Labonté, R., & Edwards, R. (2000). Indicators that count! – Measuring population health at the
community level. Toronto: Centre for Health Promotion, University of Toronto & ParticipACTION.
It is important to note that, while the focus of this paper lies at the intersection of the community
and economy spheres, this model highlights the key influence of the environment in the health
of individuals and communities. Food security is an excellent example of a determinant of
health that exists at the intersection of all spheres. Access to nutritious, affordable, safe, and
culturally appropriate food, cannot be achieved without an environment that supports
sustainable food production. Likewise, the health of the environment, clean air and water for
example, will be experienced differently based on other social and economic conditions,
(poverty, inadequate housing, etc.). The environmental sphere is an integral component of
population health and must not be forgotten when evaluating and recommending healthy public
policies.
When considered together, the above frameworks provide context for: understanding the forces
that contribute to population health; selecting comprehensive strategies for addressing the
health needs of individuals and communities; and selecting indicators for the measurement of
progress towards social and economic goals that will ultimately impact health outcomes. The
next section will elucidate further the application of these frameworks and provide a list of
possible indicators that could be adopted by local public health departments.
13
(
$
Health Determinants, Planning &
Evaluation Division
Region of Waterloo Public Health
(ROWPH)
This division, created with a goal of
shifting public health action toward social,
economic and environmental conditions that
determine health, began its journey in 1999.
Founded on the principles of the Healthy
Communities Framework (Figure 3.), this
team functions in collaboration with other
health department programs, Regional
departments and citizen groups to advance
healthy public policies. This is achieved
through the dedication of resources to
coordinate research, evaluation and
planning activities within the department and
initiatives to strengthen the capacity, of both
the division and community, to undertake
healthy public policy initiatives.
)
For the above framework to be integrated
within the existing context of public health
practice, it is necessary to develop an
understanding of existing literature regarding
the success of social policy interventions aimed
at improving the health of populations.
Furthermore, given current limitations in this
research area, public health must commit to a
research agenda that truly reflects the complex
interactions between social policies and health
and well-being. Drawing on local as well as
international examples, this section will reflect
on the question, “What do we know (and not
know) about effective interventions related to
the social and economic determinants of
health?” With this understanding in place, the
role of the public health sector, as discussed in
the previous section, will be supported through
the proposal of appropriate activities and
indicators by which to monitor progress.
As previously noted, a strong evidence base exists to support conclusions that social and
economic conditions have a significant impact on the health of both individuals and
communities. Literature also suggests that traditional interventions, aimed at fostering healthy
behaviours and lifestyles, have shown relatively little impact on reducing health disparities. In
fact, when implemented in the absence of a comprehensive population health approach, they
can actually contribute to widening the disparity gap. Universal health promotion strategies,
such as those aimed at influencing lifestyle factors and health behaviours, while beneficial to
population health in general, are frequently more effective among groups of higher
socioeconomic status. An effort to reduce health disparities requires targeted interventions
aimed at increasing opportunities for health among disadvantaged groups. Therefore, the most
effective approach to improving the health of all populations involves a balance of universal and
targeted public health actions (Health Disparities Task Group, 2004).
Whilst these aforementioned strategies include downstream behavioural programs, an upstream
approach to building healthy public policy and influencing the broad, root determinants of health
is absolutely crucial. As noted by Asthana and Halliday, however, “Very few studies focus on
wider determinants of health inequalities…much of the evidence available is located far down
the causal chain, focusing on ‘downstream’ proposals to address health behaviours and clinical
issues rather than the broader social determinants of health” (Asthana & Halliday, 2006, p. 568).
What then, can and/or should public health do to affect real and positive change in the health of
the communities it serves? Given the realities of scarce financial and human resources, and the
need to set meaningful public health priorities, this lack of “traditional” evidence has posed a
barrier to public health’s formal implementation of activities that address social conditions.
However, when other forms of research knowledge are considered, the “practice-based
evidence” of numerous policy and practice interventions emerges.
14
Working Poor Project
In December 2003, the Working Poor
Project Steering Committee was
established in partnership with Laurentian
University and the University of Toronto.
The goal of the project was to engage lowincome workers in identifying the health
and wellness issues affecting the working
poor population of the City of Greater
Sudbury.
Focus groups and key informant
interviews provided a rich source of data
and informed 7 recommendations for
action including: increasing awareness of
the existence and needs of the working
poor population; continued implementation
of health promotion activities that
specifically address the needs of the
working poor; and building partnerships to
promote and advocate for policy change
related to low-income workers.
These recommendations are now
being carried forward by community
working groups of the newly formed “Low
Wage Worker Action Group”.
Drawing from other jurisdictions, recent work
highlights the progress of several British
programs related to housing and income support.
Particularly relevant to the public health sector,
guidance and resources related to social
assistance benefits, provided in non-traditional
settings, has been shown to increase awareness
and uptake of benefits (and hence income),
access to advice workers (including home
visitors) and reduce perceived stigma among
recipients.
One example of this type of
intervention “Better Health, Better Wales”
provides residents with access to a Citizen
Advice Bureau in each of Wales’ 22 local health
authorities. As a result of these contacts, lowincome clients accessed almost £3.5 million of
additional income in one year of operation (1
British pound sterling = $2.27 CDN) (Asthana &
Halliday, 2006). As this case demonstrates,
action taken by the public health sector can have
a direct impact on social and economic
determinants of health. With increased research
and evaluation of local, provincial and federal
activities public health will be well positioned to
establish a strong evidence base for practice
related to the social and economic determinants
of health.
There are several exciting national initiatives underway to support this understanding of
effective practice. Recognizing the need to build intervention research capacity, the Canadian
Institute for Health Information (Canadian Population Health Initiative) and Canadian Institutes
for Health Research - Institute of Population and Public Health have partnered with other
agencies to examine ways to strengthen capacity for intervention research in Canada, including
interventions related to the social and economic determinants of health. The Public Health
Agency of Canada’s National Best Practices Consortium provides a promising infrastructure
through which knowledge may be furthered. Its activities address the, “need for a more
integrative and systematic approach to the population health determinants related to chronic
disease prevention such as supportive physical and social environments, education/socioeconomic status and culture” (Public Health Agency of Canada, n.d.). The Canadian Population
Health Initiative is involved with the production of a compendium of “natural experiments”
related to the social and economic determinants of health. This necessary process of evaluation
will further knowledge and appreciation of the many activities/interventions that are currently
being undertaken to address the social and economic determinants of health. As part of a
social and economic determinants of health research agenda for Ontario’s public health sector,
it will be beneficial to tap into these existing resources and infrastructures for knowledge
exchange.
15
The small body of existing empirical evidence to support public health interventions related to
the social and economic determinants of health, although challenging in terms of translation to
public health practice, has not prevented the
setting
of meaningful goals and targets both
Food Security Committee
internationally
and here in Canada. The
Algoma Health Unit
United Kingdom and Sweden are frequently
Algoma Health Unit has formed an
recognized for their commitment to reducing
internal Food Security Committee that has
health disparities. The UK, for example, has
staff representatives from all programs. One of
established a national target, “for 2010 to
the first objectives of the committee includes
reduce the gap in infant mortality across social
increasing awareness of the issue of food
groups, and raise life expectancy in the most
security with health unit staff, community
disadvantaged areas faster than elsewhere”
agencies and groups, local government and
(Department of Health, 2003, p. 3). National
the community at large. A "Community Food
headline
indicators that include measures of
Security Report" is being developed that
child poverty, education, homelessness and
includes articles/client stories on the different
housing support progress towards this goal.
strategies occurring across Algoma to address
food security. These include short-term relief
Furthermore, building on results such as those
strategies such as food banks, soup kitchens
achieved through Wales’ Citizen Advice
and student nourishment programs, skill
Bureaus, the UK Department of Health
building strategies such community kitchens,
recommends health sector action including:
community gardens and community supported
the promotion of access to welfare advice and
agriculture and community-building strategies
support in health and outreach facilities;
such as partnership on community coalitions
working
with individuals and agencies to
and providing information on how individuals
promote
home
safety and energy efficiency for
can get involved.
vulnerable families and older citizens, and that
health professionals make direct referrals to
It is a goal of the initiative to partner with
community agencies and groups to form an
energy efficiency programmes to address fuel
Algoma Food Security Action Group to
poverty (Department of Health, 2003, p. 36).
advocate at the municipal and provincial level
for policies and resources that assist in
overcoming current individual and community
food insecurities.
Similarly, Sweden has passed a national bill
(2002/03:35) to support public health
objectives. Founded on, “the creation of
social conditions to ensure good health, on
equal terms, for the entire population”, the bill’s target areas include involvement in and
influence on society; economic and social security; secure and healthy conditions for growing
up; and better health in working life (Government Offices of Sweden, 2003). These international
examples demonstrate a clear commitment to upstream approaches by the health sector to
improve population health.
Canada has also established promising national health goals. Consultations with public health
stakeholders as well as community members representing diverse interests and geographies
has led to the creation of the following overarching goal, “As a nation, we aspire to a Canada in
which every person is as healthy as they can be – physically, mentally, emotionally, and
spiritually” (Public Health Agency of Canada, 2005). The public health goals reflect a vision for
Canada where basic needs are met; citizens are supported by and engaged within their
communities; healthy choices are made accessible to all; and health care is timely, appropriate,
and responsive to the needs of individuals and communities (see Appendix C for Health Goals
for Canada). Furthermore, they are supported by a variety of federal initiatives such as those of
the Public Health Agency of Canada’s National Collaborating Centre for Determinants of Health
and the Canadian Institute for Health Information’s Canadian Population Health Initiative. Even
with respect to the renewal of Canada’s health care system, it is acknowledged that, “the health
16
care system is relatively powerless to overcome [health inequalities] on its own. We need broad
public policy to respond to the health effects of inequality and, to measure progress, we need
high-quality data linking health outcomes with the social and economic factors that influence
health” (Health Council of Canada, 2006).
Provincial level activities to address the social and economic determinants of health are also
underway. These include several of the key provincial government priorities previously
mentioned. In addition, resolutions recently adopted by the Ontario Public Health Association
(OPHA) and Association of Local Public Health Agencies (alPHa) calls for provincial review of
the Mandatory Health Programs and Services Guidelines with respect to the role of the public
health system in addressing the broader determinants of health. As previously highlighted, local
boards of health are also taking action, in a variety of creative ways, to improve the social and
economic health of their communities. Table 2 presents a summary of recommendations,
(developed as the result of provincial consultation at the determinants of health stream of the
2005 Joint conference of alPHa and OPHA) meant to assist with the future implementation of
the above framework for a provincial mandate that includes the social and economic
determinants of health. Presented according to key social and economic determinants, broad
public health goals and activities, possible community level indicators, as well as data sources
(when available), are proposed. When combined with traditional measures of health status,
monitoring of these social indicators may help to guide the actions of local public health units.
Although additional indicators have been included, most are consistent with the Core Indicators
for Public Health as generated by the Association of Public Health Epidemiologists (APHEO).
17
Table 2: Public Health Goals, Activities and Indicators to Measure Progress Related to the Social and Economic Determinants of Health
Social Determinant of Health
Sample goals and activities based on alPHa/OPHA
Conference recommendations
Income and Income Distribution
Goal
To ensure that all citizens have the financial resources
required to achieve and maintain good health.
Activities
Advocacy
The Board of Health shall advocate for and support
policies that enable all residents to have the financial
resources required to meet basic needs.
Programming
The Board of Health shall develop and enhance
initiatives that increase income adequacy, equality and
opportunities for health.
Community Capacity/Partnerships
The Board of Health shall work collaboratively with
community partners to advocate for, develop and/or
enhance policies and initiatives that increase income
adequacy, equality and opportunities for health.
Research/Reporting
The Board of Health shall produce an annual report
documenting community indicators and trends related
to income levels and income distribution.
Community Level Indicators
Data Sources
APHEO Core Indicators
Low Income Rate for All People in Private
Households
Low Income Rate For Economic Families
Children in Low Income Households (Child Poverty)
Seniors in Low Income Households (Senior Poverty)
Median share of income - Proportion of income (from
all sources, pre-tax, post-transfer) held by
households whose incomes fall below the median
household income. A proportion of 50% would
represent no inequality.
Canadian Census
Canadian Census
Canadian Census
Canadian Census
Canadian Census
Other possible indicators
Gini coefficient of income/wealth distribution
Proportion of individuals receiving social assistance
Proportion of total income received through
government transfer payments.
Ministry of
Community and
Social Services
Canadian Census
Social assistance rates as a percentage of basic
needs poverty line or LICO
18
(continued)
Education
Goal
Data Sources
To ensure that all citizens have access to quality and
diverse education and training opportunities.
Education level - Proportion of population 15 years and
over by level of schooling attained relative to the total
non-institutional population 15 years and over.
Activities
Other possible indicators
Canadian Census
Advocacy
quality and diverse education and training opportunities
for both children and adults.
Adult functional literacy rate
Proportion of children meeting developmental
standards
Programming
The Board of Health shall develop and enhance quality
and diverse education and training opportunities.
enhance quality and diverse education and training
opportunities.
Research/Reporting
to education levels.
19
(continued)
Employment
Goal
To ensure that all citizens have access to quality and
satisfying employment opportunities that enables them to
meet their basic needs.
Activities
Advocacy
policies that increase employment opportunities,
strengthen economic development and provide a living
wage for all citizens.
Programming
initiatives that increase opportunities for quality and
satisfying employment.
enhance policies and initiatives that increase
opportunities for quality and satisfying employment.
Research/Reporting
to employment patterns and wage levels.
Data Sources
Labour force participation rate - Proportion of the
population 15 years of age and over, excluding
institutional residents, who reported that they were not in
the labour force in the week (Sunday to Saturday) prior
to Census Day.
Canadian Census
Youth unemployment rate - Proportion of the
population 15-24 years unemployed relative to the
total non-institutional population 15-24 years in the
labour force in the week prior to Census Day.
Canadian Census
Long-term unemployment rate - Labour force aged
15 and over who did not have a job any time during
the current or previous year (for example, the years
1995 and 1996 for the 1996 Census).
Canadian Census
Proportion with work stress - Proportion of the
working population aged 20-64 who self-reported
that most days at work were “quite a bit stressful” or
“extremely stressful” in the past 12 months.
Canadian
Community Health
Survey (CCHS)
Other Indicators
Minimum wage as a percentage of basic needs
poverty line or LICO (based on full year of work, 40
hours/week)
Proportion of individuals working for <$10/hr
Proportion of individuals in each of permanent,
contract and casual jobs
Labour Force
Survey
Labour Force
Survey
20
(continued)
Housing
Goal
To ensure that all citizens have access to adequate,
affordable and safe housing.
Activities
Advocacy
policies that increase access to adequate, affordable
and safe housing.
Programming
initiatives that increase access to adequate, affordable
and safe housing.
enhance policies and initiatives that increase access to
adequate, affordable and safe housing.
Data Sources
Housing affordability for renters/owners/total Households (renters, owners, and total) spending
30% or more of total household income on shelter
expenses. Shelter expenses include payments for
electricity, oil, gas, coal, wood or other fuels, water
and other municipal services, monthly mortgage
payments, property taxes, condominium fees and
rent.
Canadian Census
Other indicators
Number of individuals who are homeless or at risk of
homelessness
Local data source
Utilization of local shelters
Local data source
Number of individuals/families on local waitlists for
social housing
Municipal Housing
Authority
Vacancy rate
Canada Mortgage
and Housing
Corporation
Research/Reporting
to the accessibility/availability of adequate, affordable
and safe housing.
21
(continued)
Social Inclusion
Goal
To ensure that all citizens report a sense of social
inclusion and have opportunities for meaningful
participation in community life.
Other indicators
Proportion of individuals that rate their sense of
community belonging as very strong
Data Sources
Canadian
Community Health
Survey (CCHS)
CCHS
Activities
Advocacy
policies and initiatives that encourage social inclusion,
community participation and civic engagement.
Proportion of individuals reporting a high degree of
social support
Availability of Social Support
CCHS
Programming
initiatives that increase social inclusion and
opportunities for meaning participation in community
life.
Utilization of Social Support
CCHS
enhance policies and initiatives that increase social
inclusion and opportunities for meaningful participation
in community life.
Note: Other social and economic determinants indicators
that contribute to exclusion – poverty, housing,
education, etc, are frequently used to measure social
inclusion.
Research/Reporting
to social inclusion.
22
(continued)
Food Security
Goal
To ensure that all citizens have access to nutritious,
affordable, appropriate and locally produced food.
Activities
Advocacy
policies and initiatives that increase access to
nutritious, affordable, appropriate and locally produced
food.
Programming
initiatives that increase access to nutritious, affordable,
appropriate and locally produced food.
enhance policies and initiatives that increase access to
nutritious, affordable, appropriate and locally produced
food.
Data Sources
Food insecurity rate - Proportion of the population
who, because of lack of money, worried that there
would not be enough to eat or didn’t have enough
food to eat or didn’t eat the quality or variety of foods
that they wanted to eat.
Canadian
Community Health
Survey
Other indicators
Utilization of local food banks
Cost of nutritious food basket (as a percentage of
average incomes and social assistance rates)
Local data source,
Canadian
Association of Food
Banks
Local Public Health
Unit data
Research/Reporting
to food security.
23
This “basket of indicators” serves as a first draft for a method of evaluation of public health
activities related to the social and economic determinants of health. Their effective application
to public health practice, however, depends on the further refinement of public health activities
as well as specific public health process indicators and appropriate targets. The diversity of
communities served by public health demands a flexible approach to the implementation and
measurement of activities related to the social and economic determinants of health. Input
from public health stakeholders at the provincial level, as well as local communities will be
critical to this process. To further support this ongoing process of consultation, experience,
such as demonstrated by the local initiatives highlighted above, suggests that community
engagement related to the determinants of health has the potential to achieve more than one
desired outcome. Whilst providing an assessment of community needs and strengths,
consultation in itself addresses social and economic determinants of health goals such as
increasing opportunities for meaningful citizen engagement and community participation.
Additional factors that will influence the integration of these activities and indicators include the
availability of data at the local/community level and the aforementioned knowledge gaps related
to the mechanisms through which social conditions impact individual and community health.
Ultimately, however, the translation of a social and economic determinants framework into
public health practice will depend on: a common understanding of the causes of health
inequalities; further research related to the effectiveness of public health interventions related to
the social and economic determinants of health; and, the will of all community and government
sectors to invest in the health of Ontarians in its broadest sense.
Development of a Health Status Report has been identified as a priority activity for The Ontario
Agency of Health Protection and Promotion (Agency Implementation Task Force, 2006). With
the above-mentioned factors in mind, it is recommended that the health status report include
public health indicators for social and economic determinants of health. The Agency report must
provide an overview of provincial health status but be further subdivided by public health region,
allowing for health status improvement targets and initiatives to be set both at the provincial and
local levels. If framed within a determinants of health approach, health status reporting can be a
powerful tool at illuminating health disparities. Its is recommended that all health status reports
(whether at provincial or local levels) be required to analyze disparities for every health outcome
discussed in order to identify and monitory vulnerabilities hidden by the reporting of averages.
Health disparities are such that simply reporting averages over time masks the effects of socialeconomic factors on health outcomes.
24
(
&
)
In the 2005 annual report of Dr. Basrur, the Chief Medical Officer of Health, Building the
foundation of a strong public health system for Ontarians (Basrur, 2005), several key messages
are worth highlighting. Dr. Basrur reiterated the cautions of Dr. David Butler-Jones, stating that
work on “patching cracks without fixing the foundation” in this phase of rebuilding our public
health system must be avoided (Basrur, 2005, p. 5). Dr. Basrur also acknowledged that in
addition to current mandated program areas, the social, economic and environmental
determinants of health are also seen as strategic areas requiring public health action.
The following section outlines four fundamental roles that public health in Ontario should
undertake as priority areas for immediate action, which include leader, change agent,
knowledge broker, and multi-sectoral collaborator.
Leader
Dr. Basrur outlined some of the initiatives that have been undertaken to strengthen the public
health system with respect to outbreak management (Basrur, 2005). While these initiatives are
important, similar provincial leadership commitments are required to assist the health system in
Ontario to address broad social and economic determinants of health. For example, the
formation of a multi-sectoral provincial advisory committee to provide expert advice to public
health practitioners and government officials; the creation of regional networks to improve local
coordination and communication; and broad determinants of health training for health care
workers and community partnerships/networks. The advisory committee’s work should include
strengthening public health’s capacity to understand and undertake health impact assessments,
especially as it relates to policy decisions. This particular function was also a recommended
outcome from the Canadian Population Health Initiative Roundtable discussions held in
March 2002.
Another noteworthy provincial government initiative outlined in Dr. Basrur’s report (2005) is the
establishment of an Interministerial Committee on Healthy Living chaired by the Minister of
Health Promotion (Basrur, 2005). Often times decisions made outside the health care system
have a direct impact (either positive or negative) on health, on health inequities, and ultimately
on the health care system (e.g. social programs, housing, education, etc.) (CIHI, 2004). The
composition of this committee creates a fertile environment for tackling broad determinants of
health. Other examples of local/provincial leadership have been demonstrated by a subgroup of
the Council of Ontario Medical Officers of Health (COMOH). A COMOH working group on social
and economic determinants of health has been instrumental in championing work on addressing
the broad determinants of health.
Change agent
Public health must work on acquiring and maintaining public support for addressing the social
and economic determinants of health. The stronger the public support, the better chances of
influencing political will to implement policies that address health disparities in a positive way.
This includes individuals and groups from all diverse non-government sectors and levels of
government. In particular, municipal governments will continue to be essential allies in
influencing and implementing healthy public policies. The 2004 Canadian Population Health
Initiative report, Improving the health of Canadians, demonstrates that most people associate
behaviours, lifestyle, and the environment as important determinants of health, but only 33%
recognized the health impact of social conditions such as income, housing and supportive
25
community networks. Clearly, the public health tobacco success story of this decade
demonstrates that when public health champion’s a cause, it can succeed in educating the
public on key issues, fostering support for action and policy development. Public health can and
should play a key role in addressing broad determinants of health in a comprehensive manner
as it has done with tobacco.
Knowledge broker
We need to foster continued evaluation and knowledge exchange initiatives in the areas of
surveillance, monitoring, and reporting. This would include expanded research and evaluation of
the effectiveness of specific public health interventions related to the social and economic
determinants of health. It is encouraged that we promote an environment where multiple
methodological frameworks are valued, for example qualitative and mixed methods. In addition,
we need to advocate for the increased collection of and access to community level data as part
of existing health data collecting infrastructures (e.g. CCHS, Canadian census, RRFSS). Lastly,
expanding our ability to undertake health impact assessments of policy initiatives is fundamental
to the work of bringing knowledge of social and economic determinants of health to bear on key
decision-making processes.
Multi-sectoral collaborator
As has been demonstrated in the body of this paper, addressing the broad determinants of
health requires that public health engage in non-traditional partnerships to ensure coordinated
policies and programs (CIHI, 2004). Public health must strive to facilitate and support
participation from public, private and voluntary sectors when planning, implementing and
evaluating various strategies. Furthermore we must support collaborative action on setting
priorities and policy direction, as well as sharing resources and expertise.
Much of the information contained within this discussion paper supports action by the public and
policymakers to turn their attention towards some of the neglected health issues mentioned
under the need section. With effective political and public health leadership, collaborative efforts
between government, the private sector, and voluntary organisations, and the development of
policies and practices based on the best available evidence from a variety of sources, Ontario
can be on the leading edge of addressing the social and economic determinants of health,
reducing health inequities and improving overall population health.
Challenges related to the integration of social and economic determinants of health standards
(general and program) within the next generation of the public health system’s Mandatory
Health Programs and Services Guidelines include:
Public perception and understanding of the links between the social determinants of health
(such as income, education and employment) and health is lacking (CIHI, 2005).
Progress on the social and economic determinants of health will most likely occur in the long
term and attribution to public health programs will be difficult.*
Social and economic determinants are influenced by a variety of political and community
stakeholders (e.g. community and social services, education, labour, agriculture), therefore
blurring accountabilities and responsibilities.*
The public health workforce does not necessarily reflect the diversity of the communities it
serves making it more difficult to connect/represent our diverse population groups.*
26
Action on the social and economic determinants of health requires reflection and
acknowledgement of our own personal values and attitudes (fear of a loss of power; covert
discrimination).*
Implementation of a social and economic determinants of health mandate is not necessarily
revenue neutral. Strategic allocation or reallocation of resources will be necessary.
There are gaps in “traditional” evidence and knowledge transfer related to the social and
economic determinants of health.*
* these challenges were identified by the Determinants of Health stream participants at the 2005 alPHa/OPHA
Conference.
Although these challenges are real, they are not insurmountable and do not justify inaction. The
recommendations and next steps section that follows identifies strategies that will help public
health to overcome these potential barriers.
'
&' $
(
This document provides clear argument for the following recommendations:
1. That a general and a program standard related to the social and economic determinants
of health be incorporated in the revisions to the Mandatory Health Programs and Services
Guidelines (MHPSG).
2. That the models and frameworks presented in this paper be adopted within the new
MHPSG.
3. That an interministerial committee be assembled as soon as possible with key inservices
related to the health impact of social and economic conditions and opportunities for policy
recommendations and implementation.
Furthermore, this paper demonstrates that public health is positioned to take the lead and can
make significant gains in improving health status through the development of baseline
measures, increasing a focus on upstream strategies to reducing inequities in health and
measuring and reporting on progress. Relevant conceptual frameworks as well as social and
economic indicators have been recommended. In addition, essential roles and public health
initiatives have been identified. However, for the above recommendations to be successfully
applied to public health practice, enhanced infrastructures, resources, and capacities, as well as
increased flexibility regarding the use of existing resources must be in place. The following next
steps are recommended in order to achieve an effective and efficient transition to incorporating
social and economic determinants of health into public health practice:
27
4. Consultation – In keeping with the recommendations of the 2005 Joint Conference of
alPHa and OPHA, a revised public health mandate would address social and economic
determinants of health as both a general standard (applied across public health programs
and activities), as well as a stand-alone program standard. Whilst this document lays the
foundation for the development of such a mandate, further consultation with key
community and public health stakeholders is necessary in order to refine the social and
economic program standards, indicators and specific public health activities and targets.
The reference group, composed of Medical Officers of Health, as well as other provincial
and federal agency representatives (OPHA, alPHa, OPC, CIHI) that guided the
recommendations of this paper will pursue this necessary consultation and provide the
Ministry of Health and Long-Term Care with further specific mandate recommendations.
In addition, broad dissemination of this discussion paper to local public health agencies is
recommended in order to serve as a basis for further discussion regarding
recommendations for a Framework to Integrate Social and Economic Determinants of
Health into the Ontario Public Health Mandate.
5. Research and knowledge exchange – Further to recommendations of the Agency
Implementation Task Force (2006), the development of a province-wide network for public
health research, training and knowledge exchange must support an agenda that includes
research and tool development relating to the social and economic determinants of
health. Specifically, increased knowledge related to public health interventions aimed at
addressing social and economic conditions is critical and can be achieved, in part through
the establishment of links with existing provincial and national initiatives, (e.g. Public
Health Research & Evaluation Division, National Best Practices Consortium, Canadian
Population Health Initiative).
6. Healthy public policy assessment and advocacy – Formal, interministerial structures are
necessary in order to effectively conduct health impact assessments related to new and
existing public policies, especially as it relates to the social and economic determinants of
health. As the health of populations is impacted by the mandates of a variety of provincial
ministries, collaboration between ministries is essential to the establishment of healthy
communities and public policies.
7. Public health capacity building – The introduction of a mandate that incorporates social
and economic determinants of health will necessitate training of and capacity building for
local boards of health and public health staff. A province-wide network for public health
research, training and knowledge exchange, (Agency Implementation Task Force, 2006)
must support training related to the social and economic determinants of health as well as
the local conduct of health impact assessments. In addition, a provincial resource centre
(e.g. Ontario Prevention Clearinghouse) is required to provide consultation and expert
advice to public health units on the social and economic determinants of health similar to
other resource centres (e.g. Heart Health).
With these recommendations in place, an exciting phase begins – one that redefines the role of
public health in Ontario. A shift in the focus of public health activities, towards the social and
economic determinants of health, has the great potential to improve opportunities for health for
all Ontarians.
28
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31
32
((
33
34
!
"
"
Overview of Determinants of Health Stream at the Joint Conference of the Association of Local
Public Health Agencies (alPHa) and the Ontario Public Health Association (OPHA) Determining
Health Through Public Health Action
GENERAL STANDARD / FRAMEWORK ON
SOCIAL AND ECONOMIC DETERMINANTS OF HEALTH
GOAL:
To improve the health of all of the population by reducing the social, economic and
cultural inequalities and conditions which cause ill health.
Objectives:
1.
To ensure that all programs and services explicitly address the social and economic
determinants of health as appropriate.
PROPOSED PROGRAM STANDARD
SOCIAL AND ECONOMIC DETERMINANTS OF HEALTH
INCOME EQUALITY
Objective would relate:
1.
To increase the number of people who have the financial resources to meet basic needs
(i.e. a living wage, adequate social assistance, etc.)
SAFE AND AFFORDABLE HOUSING
Objective:
1.
To increase the number of people who are living in safe and affordable housing (i.e.
social housing, various forms of rent support, etc.)
EDUCATION / SKILL BUILDING / LITERACY
Objectives:
1.
To increase opportunities for education and skill building for all people.
2.
To increase the percentage of people who achieve a minimum grade 12 literacy and
numeracy level.
SOCIAL INCLUSION
Objective:
1.
To increase the proportion of the population who report a sense of community, social
connection and inclusion.
FOOD SECURITY
Objective:
1.
To increase the proportion of the population who have access to affordable, healthy,
locally produced food.
35
EMPLOYMENT AND JOB SECURITY / ECONOMY
Objective:
1.
To increase the proportion of the population who have access to secure and satisfying
employment.
COMMUNITY CAPACITY / PARTNERSHIPS
Objectives:
1.
To increase public knowledge and understanding of the social and economic
determinants that affect individual and community health and well-being.
2.
To increase and strengthen partnerships with organizations/agencies and communities
engaged to act on the social and economic determinants of health.
3.
To increase citizen engagement and influence in decision-making aimed at reducing
health inequalities.
ACCESS TO SERVICES
Objectives:
1.
To reduce educational, social and environmental barriers to accessing public health
services that promote equity in health.
2.
To increase access to services that promotes equity in health (e.g. day care, dental,
etc.).
MENTAL HEALTH PROMOTION
Objective:
1.
To improve the mental health status of the general population (children, youth, adults,
and older adults.)
RESEARCH
Objective:
1.
To increase the number of research and evaluation initiatives which increase public
health unit understanding of the social and economic determinants of health in their
community and the number of intervention evaluations related to the social and
economic determinants of health.
36
The following is the list of Conference Stream participants, as registered for the conference,
who worked on the Draft Proposed General and Program Standards for the Social Determinants
of Health.
Mary
Golbourne
Board of Health, Kingston, Frontenac and Lennox & Addington
Health Unit
Mayor Ron
Maguire
Board of Health, Kingston, Frontenac and Lennox & Addington
Health Unit
Sheila
Basrur
Chief Medical Officer of Health for Ontario
Lisa
Sullivan
The Canadian Institute for Health Information
Glenda
McArthur
City of Hamilton
Heidi
McGuire
City of Hamilton Public Health Services
Kevin
Churchill
County of Lambton, Community Health Services
Angela
Cooper Brathwaite
Durham Region Health Department
Judith
Murray
Jean
Nesbitt
Kavine
Thangaraj
Lynda
Bumstead
Grey Bruce Health Unit
Maureen
Handley
Hazel
Lynn
Bill
Pettingill
Haliburton, Kawartha, Pine Ridge District Health Unit
Ric
McGee
Haliburton, Kawartha, Pine Ridge District Health Unit
Beth
Henning
Huron County Health Unit
Penny
Nelligan
Huron County Health Unit
Anne
Taylor Barnett
Leeds, Grenville and Lanark District Health Unit
Denise
Kall
Rani
Tolton
Margaret
Black
McMaster University
Marlene
Mirza
McMaster University
Jane
Underwood
McMaster University
Bernard
Lueske
Middlesex-London Health Unit
James
Madden
Pat
Sealy
Piotr
Wilk
Rose
Bilotta, Dr
Ministry of Health and Long-Term Care, Public Health
Helen
Brown
Ministry of Health and Long-Term Care
Brenda
Perkins
Marg
Rappolt
37
Sylvia
Shedden
John
Yudelman
Ministry of Health Promotion
Donna
Kalailieff
Niagara Region Public Health
Patti
Moore
Norfolk County - Health & Social Services Department
Gwen
MacDougall
North Bay Parry Sound District Board of Health
Catherine
Whiting
North Bay Parry Sound District Health Unit
John
Albanese
Northwestern Health Unit
Valerie
Mann
Pete
Sarsfield
Julie
Roy
Heather
Christian
Nova Scotia Department of Health
Connie
Clement
Ontario Prevention Clearinghouse
Arlette
Brobyn
Regional Municipality of Peel Health Department
Gayle
Bursey
Paula
Dall'
Osto
Bev
Hardy
Hanif
Kassam
Dorina
Rico
Noel
Saraza
Aarti
Soni
Rosana
Pellizzari
Perth District Health Unit
Garry
Humphreys
Peterborough County-City Health Unit
Paul
Jobe
Maureen
McKeen
David
Watton
John
Piper
Playter Strategies Limited
Gil
Hebert
Porcupine Health Unit
Jos
Matko
Maurice
Tanguay
Chito
Diorico
Public Health Agency of Canada
Godwin
Jogarajah
Sam
Kiros
Marilyn
Tate
Barbara
Dyszuk
Betty
Pittman
Theresa
Schumilas
38
Jack
Lee
retired
Shawn
Fendley
Simcoe Muskoka District Health Unit
Charles
Gardner
Simcoe Muskoka District Health Unit
Toba
Bryant
St. Michael'
s Hospital
Peggy
Weston
student
Christine
Yakiwchuk
student
Ginette
Comeau
Chris
Coulombe
Vera
Etches
Janet
Gasparini
Phyllis
Kinoshameg
Nancy
Lacasse
Sandra
Laclé
Marie
LaFramboise
Stephanie
Lefebvre
Penny
Sutcliffe
Claire
Warren
Shelley
Westhaver
Brian
Hyndman
The Alder Group
Doug
Heath
Thunder Bay District Health Unit
Maureen
Twigg
Thunder Bay District Health Unit
Esther
Millar
Timiskaming Health Unit
Kerry
Schubent-Mackay
Timiskaming Health Unit
Cecilia
Alterman
Toronto Public Health
Ida
Hersi
David
McKeown
Fran
Scott
Catherine
Turl
Caroline
Wai
Ingrid
Tyler
University of Toronto
Randy
Johner
University of Regina
Christina
Mills
University of Waterloo
Lynn
Beath
Wellington-Dufferin-Guelph Health Unit
Troy
Herrick
Elaine
Scott
Elizabeth
Haugh
Windsor-Essex County Health Unit
39
Allen
Heimann
Windsor-Essex County Health Unit
Diane
Bladek-Willett
York Region Health Services Department
Dennis
Raphael
York University
Lisa
Ashley
Alexander
Hukowich
Brendan
Smith
40
#
$
$
%
$
Health Canada, Population and Public Health Branch. (2001). The population health template: Key elements and
actions that define a population health approach. Retrieved March 27, 2006, from http://www.phac-aspc.gc.ca/phsp/phdd/pdf/discussion_paper.pdf
41
42
!
OVERARCHING GOAL
As a nation, we aspire to a Canada in which every person is as healthy as they can be –
physically, mentally, emotionally, and spiritually.
HEALTH GOALS FOR CANADA
Canada is a country where:
Basic Needs
(Social and Physical Environments)
Our children reach their full potential, growing up happy, healthy, confident and secure.
The air we breathe, the water we drink, the food we eat, and the places we live, work and play
are safe and healthy - now and for generations to come.
Belonging and Engagement
Each and every person has dignity, a sense of belonging, and contributes to supportive families,
friendships and diverse communities.
We keep learning throughout our lives through formal and informal education, relationships with
others, and the land.
We participate in and influence the decisions that affect our personal and collective health and
well-being.
We work to make the world a healthy place for all people, through leadership, collaboration and
knowledge.
Healthy Living
Every person receives the support and information they need to make healthy choices.
A System for Health
We work to prevent and are prepared to respond to threats to our health and safety through
coordinated efforts across the country and around the world.
A strong system for health and social well-being responds to disparities in health status and
offers timely, appropriate care.
Public Health Agency of Canada. (2005). Health goals for Canada: A federal, provincial and territorial commitment to
Canadians. Ottawa: Author.
43

A Framework to Integrate Social and Economic Determinants of

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