public awareness and understanding of health i nequalities in ontario
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Public Awareness and Understanding of Health Inequalities in Ontario
Ketan Shankardass, PhDDepartment of Psychology, Wilfrid Laurier UniversityCentre for Research on Inner City Health in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital
November 30, 2012
Outline1.The link between public awareness and political will for health equity
2.Ontario public awareness of health inequalities
3.Implications for broadening awareness of SDoH in Ontario
Health
Social Determinantsof Health
Health Sector
Health Services
(Adapted from World Bank, 2011)
How broad is your health system?
HealthSystem
Need to strengthen chronic disease prevention, e.g., Diabetes in Ontario
(Canadian Diabetes Association, 2010)
…particularly among those with mid/low income
Neighbourhood ‘activity-friendliness’ predicts diabetes in Toronto...
(Booth et al, 2007)
Why not broaden action on the social determinants of health?•Why not tackle the growing health and
economic burden of diabetes and obesity – and reduce inequities in these outcomes – by supporting measures to ensure that all Ontarians have adequate:▫Family income▫Food security▫Neighbourhood activity friendliness
Political will as a key driver of action on the social determinants of health
Problem stream
Policy stream
Political stream
Window of Opportunity to Act on SDoH
Public Awareness and Understanding as a
Driver of Political Will(Kingdon, 1984)
Public Opinion on Health Inequalities in Ontario•Telephone survey using random digit dialling•2006 Ontarians aged 18 years and over•Survey conducted in 2010 fall/winter•The survey included questions pertaining to
three broad themes: 1. awareness of health inequalities2. attributions of the causes of health
inequalities3. opinions about solutions to health
inequalities
Public Awareness of Health Inequalities in Ontario• Respondents asked to agree/disagree with four
statements about health inequalities in general and by income in Ontario:1. In Ontario, all people are equally healthy and can
expect to live for more or less the same amount of time2. In Ontario, people who are rich are much healthier
than those who are poor3. In Ontario, people who are poor are less likely to live
into their 80s than people who are rich4. Over the last few years, people who are rich have
become healthier while people who are poor have become less healthy
Public Awareness of Health Inequalities in Ontario1. In Ontario, all people are equally
healthy and can expect to live for more or less the same amount of time
2. In Ontario, people who are rich are much healthier than those who are poor
3. In Ontario, people who are poor are less likely to live into their 80s than people who are rich
4. Over the last few years, people who are rich have become healthier while people who are poor have become less healthy
73% disagreed
53% agreed
64% agreed
57% agreed
(Shankardass et al 2012)
11%
The rich are less likely to suffer from...
05
10152025303540
% agree-ment among Ontarians
~20%
(Shankardass et al 2012)
So what?•A small majority of Ontarians are aware of
income-related health inequalities▫30% in a 2005 national study (CIHI 2005)
▫82% in a 2004 study in Saskatoon (Lemstra et al 2007)
So what?•Much lower awareness of income-related
inequalities in specific health conditions▫Even Ontarians who are generally aware
have an incomplete understanding of the breadth of the issue
So what?•There is a need for more “knowledge
translation” of evidence outlining inequalities
•Aim to:a. Reduce the size of the core minority who
remain unaware b. Improve awareness about the variety of
outcomes impacted•Which Ontarians to target? How to frame
the issue to those groups?
Younger Ontarians are less aware of income-related inequalities
18-34 35-54 55+0
0.2
0.4
0.6
0.8
1
1.2
Age Group
RelativeOdds
Comparedto YoungestAge Group
“The rich are much healthier than the poor”
(Shankardass et al 2012)
Females are less aware of income-related inequalities than males
0
0.4
0.8
1.2
RelativeOddsfor
Males
(Shankardass et al 2012)
Rural Ontarians are less aware of income-related inequalities
The rich are much healthier than the poor
Alcoholism Obesity0
0.2
0.4
0.6
0.8
1
1.2
RelativeOddsfor
Urban Areas
(Shankardass et al 2012)
Ontarians with low educational attainment are less aware of income-related inequalities
0
1
2
RelativeOddsfor
High SchoolAttainment
(Shankardass et al 2012)
Ontarians who don’t vote NDP or Liberal are less aware of income-related health inequalities
The rich are much healthier than the
poor
Diabetes0
0.4
0.8
1.2
Heart Disease
Accidents Diabetes Lung Disease
00.20.40.60.8
11.2
Relative Oddsfor NDP Voters
Relative Oddsfor Liberal
Party Voters
(Shankardass et al 2012)
- Unequal health opportunities versus unequal outcomes
- Explaining the role of external factors in clear and compelling ways
- A clear and practical vision of how to solve the problems
- Health as an exceptional case- Explaining the health gradient (“a grand challenge”)
To move the public away from the “right choices” model:
Attributions for income-related health inequalities among Ontarians, by political affiliation
(Lofters et al, unpublished)
Moving the SDoH agenda forwardIn Ontario, we need to strengthen public awareness about income-related inequalities…- Generally and about specific outcomes- Particularly among Ontarians who are:
- Younger- Female- Rural- With low educational attainment- Who vote Progressive Conservative
- Focus on translating explanations related to:- Neighbourhoods and health- Accessibility of the health care system- Disempowering effect of low income
Health in All Policies as health promotionAdvocate for political/economic/social/ cultural/environmental/biological/behavioural conditions favourable for health and equity
• Continue to work on clearly and concisely articulating links amongst health determinants and health/equity outcomes• Build the case for a multisectoral approach,
one sector at a time• Build public awareness and understanding of
health determinants and “population health”
Health in All Policies as health promotionMediate the specific interests of actors in the pursuit of health and equity
E.g., Health Impact Assessment using “win-win approach”• Health diplomacy “to make the healthier
choice the easier choice for policy makers” (Krech, 2011)
• May involve trade-offs initially to foster durable relations with increasingly health-aware partners
• Good cop-bad cop? The need for legislation to compel action, as needed
Social marketing?• Considering a “social marketing” perspective can
help think about messaging that will resonate with specific under-aware subpopulations
• Consumer-oriented marketing techniques have been used in the design, implementation and evaluation of health promotion aiming to influence behaviours
• Incorporates the four “Ps” of marketing▫Place – who are you trying to target?▫Product – what are you trying to sell?▫Price – how “costly” is buy-in?▫Promotion – what approach will promote buy-in?
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