action on the social determinants of health: the role of local public health units
DESCRIPTION
Action on the Social Determinants of Health: The Role of Local Public Health Units. Dennis Raphael, PhD School of Health Policy and Management York University Presentation to the Peterborough County/City Board of Health, Peterborough, Ontario October 12, 2011. Overview of Presentation. - PowerPoint PPT PresentationTRANSCRIPT
1
Action on the Social Determinants of Health: The Role of Local Public
Health Units
Dennis Raphael, PhDSchool of Health Policy and Management
York University
Presentation to the Peterborough County/City Board of Health, Peterborough, Ontario
October 12, 2011
2
Overview of Presentation
• The importance of the social determinants of health (SDH)
• Type 2 diabetes as an illustration of the importance of the SDH in incidence and management of the disease
• The role of public health units in educating and mobilizing the public to address the SDH
3
What are Social Determinants of Health?
• Social determinants of health are the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.
• Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.
4
The Canadian Perspective • Aboriginal status• disability• early life• education• employment and
working conditions• food security• health services
• gender• housing• income and income
distribution• race• social exclusion• social safety net• unemployment
Source: Mikkonen, J. and Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. On-line at http://thecanadianfacts.org
5
Social Determinants of Health SDOH can affect health in a number of ways:• Social determinants define the prerequisites for
health, such as shelter, food, warmth, and the ability to participate in society;
• Social determinants can cause stress and anxiety which can damage people’s health;
• Social determinants limit peoples’ choices and militates against desirable changes in behaviour.
Source: Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.
6
Poverty is the clustering of exposures to adverse social
determinants of health
(not to belabour the point, but very few poor people live in mansions and eat “healthy”
diets and very few rich people are at risk of homelessness or going hungry)
7
Social determinants of health (SDH) are the primary factors
shaping health
8
Diabetes prevalence by age and income
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20 - 29 30 - 44 45 - 59 60+
Source: Statistics Canada Canadian Community Health Survey
Prev
alen
ce NO INCOME or < $29,999
$30,000-$79,999
$80,000 or more
9
Figure 4. Increased Risk of Type 2 Diabetes for Lower Income Men not Affected by Weight or Physical Activity
2.07 1.94 1.72 1.66
0
1
2
3
Income <$15,000
Education,Weight, and
Physical ActivityTaken into
Account
Income $15,000-29,999
Education,Weight, and
Physical ActivityTaken into
Account
Lower Income Groups
Incr
ease
d R
isk
of
Ty
pe 2
Dia
bete
s
Source: Adapted from Dinca-Panaitescu, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). Diabetes prevalence and income: Results of the Canadian Community Health Survey. Health Policy, 99, 116–123
10
Figure 5. Increased Risk of Type 2 Diabetes for Lower Income Women Slightly Affected by Weight and Physical Activity
3.572.75 2.58
2.1
0
12
3
4
Income <$15,000
Education,Weight, and
PhysicalActivity Takeninto Account
Income $15,000-29,999
Education,Weight, and
PhysicalActivity Takeninto Account
Lower Income Groups
Incr
ease
d R
isk
of T
ype
2 D
iabe
tes
Source: Adapted from Dinca-Panaitescu, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). Diabetes prevalence and income: Results of the Canadian Community Health Survey. Health Policy, 99, 116–123
11
Figure 6. Increased Risk of Developing Type 2 Diabetes over a two year Period for Canadians Living in Poverty
1.24 1.28 1.26 1.24
0
0.5
1
1.5
Living inPoverty DuringPeriod Prior to
DevelopingDiabetes
Adjusted forObesity and
PhysicalInactivity
Living inPoverty at Any
Time Duringthe Course of
the Study
Adjusted forObesity and
PhysicalActivity
Poverty Situation
Incr
ease
d R
isk
of T
ype
2 D
iabe
tes
Dinca-Panaitescua, S., Dinca-Panaitescu, M., Bryant, T., Daiski, I. Pilkington, B. and Raphael, D. (2011). The dynamics of the relationship between poverty experience and type 2 diabetes: Longitudinal results. York University: SHPM.
12
SDH shape access to care, management of illness, and
recovery from illness
13
Figure 1. Diabetes Mortality, Urban Canada, 1971-2001, Males
0
5
10
15
20
25
1971 1976 1981 1986 1991 1996 2001
Mor
talit
y R
ates
Per
100
,000
Q1 - RichestNeighbourhoods
Q2
Q3
Q4
Q5 - PoorestNeighbourhoods
Source: Wilkins, R. (2007). Mortality by Neighbourhood Income in Urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar, and Special Compilations.
14
Figure 2. Diabetes Mortality, Urban Canada, 1971-2001, Females
0
5
10
15
20
25
1971 1976 1981 1986 1991 1996 2001
Mor
talit
y R
ates
Per
100
,000
Q1 - RichestNeighbourhoods
Q2
Q3
Q4
Q5 - PoorestNeighbourhoods
Source: Wilkins, R. (2007). Mortality by Neighbourhood Income in Urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar, and Special Compilations.
15
SDOH of Type 2 Diabetes Study
• Objectives:– Examine the experiences and living conditions of
low-income persons with type 2 diabetes.– Place findings in the context of the social
determinants of health.• Methodology:
– 60 in-depth interviews with individuals with Type 2 Diabetes and focus groups with service providers.
– Thematic analysis of interview content.– Also, content analysis according to key social
determinants.
16
Food
72% of participants indicated that they lacked the economic resources required to acquire the kind of diet they knew they must follow.
17
FoodI. Do you have enough money to get the kind of food you’d like to
get?P. Not really. [laughs] No money. Plus the rent is high too. So I
haven’t got very much you know.I. So it doesn’t leave you a lot of money.P. No. That’s why I go to the church and, sometimes they give
you-- they have stuff on the table, like some groceries you take.I. Hmm. Do you find that sometimes you have to eat food that you
know you probably shouldn’t eat?P. Yeah. But I don’t eat donuts and stuff, because it’s got a lot of
sugar, right? They say that everything you eat, you know, turns into sugar except the vegetables. [ male, 53 years]
18
Social Assistance Levels do not Allow for Health
Welfare Assistance Situation for persons in Ontario, 2008 Single Person Considered
Employable
Single Personwith a Disability
Lone Parent with Child Aged Two
Couple with Two Children Aged 10 & 15
Total Income $7,352 $12,647 $16,683 $21,215
Benefits Decline
from 1992
$4,04836%
$3,06920%
$5,76112%$
$8,67429%
Source: National Council of Welfare (NCW) (2010). Welfare Incomes, Nos. 1-4. Ottawa: NCW
19
Figure 3.5: Total Average Income by Income Quintile, All Family Units, Canada, 1995-2008
15,00013,100
55,10047,500
169,000
128,400
020,00040,00060,00080,000
100,000120,000140,000160,000180,000
Lowest Quintile Second Quintile Middle Quintile
Fourth Quintile Highest Quintile
Figure 5. Number of Canadians Assisted by Food Banks: 1989-2010 (March of Each Year)
0200,000400,000600,000800,000
1,000,000
89 97 98 99 00 01 02 03 04 05 06 07 08 09 10
Year
Num
ber A
ssist
ed
Source: Food Banks Canada (2011). Hunger Count. Toronto: Food Banks Canada.
21
Adverse SDH and Public Policy
The Canadian Public Health Association: “Policies shape how money, power and
material resources flow through society and therefore affect the determinants of health. Advocating healthy public policies is the most important strategy we can use to act on the determinants of health.”
22
Citizen involvement is a primary means of influencing the quality of the SDH and affecting health
and health care outcomes
23
The Role of Public Health Units
24
Ontario Public Health Standards 2009
• Addressing determinants of health and reducing health inequities are fundamental to the work of public health in Ontario.
• Effective public health programs and services consider the impact of the determinants of health on the achievement of intended health outcomes.
25
Ontario Public Health Standards 2009
• The board of health shall provide population health information, including determinants of health and health inequities to the public, community partners, and health care providers, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).
• Dissemination of surveillance analyses may take the form of reports, advisories, healthy public policy recommendations, alerts, or warnings.
26
Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.
Source: Commission on the Social Determinants of Health. (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants Of Health. Geneva: World Health Organization.
The Way Forward
27
In a 2010 survey of the 36 public health units in Ontario, only two of
the 23 responding units had undertaken “community education and awareness campaigns” about
the SDH
28
29
30
Canadian Democracy!• It shall be lawful for the Queen, by and with
the Advice and Consent of the Senate and House of Commons, to make Laws for the Peace, Order, and good Government of Canada – Canadian Constitution 1867/1982
• “Citizens in a democracy have the right -- even obligation -- to participate meaningfully in public decision-making and to be informed about the bases of government policies.”
• Frank Fischer. Reframing Public Policy 2003
31
Summary: The Social Determinants of Health
• Social determinants of health (SDH) are the primary factors shaping health
• SDH shape access to care, management of illness, and recovery from illness
• Citizen involvement is a primary means of influencing the quality of the SDH and affecting health and health care outcomes
• Public health units have an important role in public education about the SDH
32
Learn more…
33
34
35
36
thecanadianfacts.org
37
Dennis Raphael
This presentation and other presentations and related papers are available at:
http://www.atkinson.yorku.ca/draphael
[go to the library there]