When starting the Critical Foundations in Health Disciplines course, I had no idea which direction it would take me in. This course has resulted in my curation of knowledge and my understanding of the various effects that influence Canadians within the healthcare system. Throughout this course I have touched on chronic conditions, intimate partner violence, indigenous peoples, low-income vulnerable people and our senior population. When looking back, my focus was on these groups individually and the issues which are specific to these groups. When deciding which one to concentrate on for this blog I realized that they are all very much entwined. So ultimately, I decided to focus on the inequities and determinants of health that link them together. These are all vulnerable groups that are impacted by various health inequities and determinants of health.
I will focus on determinants of health, health equities and some principles and practices that can be adapted to advance health equity within the Canadian context.
Determinants of Health
The World Health Organization (WHO) defined determinants of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (1948) The Canadian Public Health Association goes further in discussing the Social Determinants of Health (SDH). SDH refer to a specific group of social and economic factors within the broader determinants of health. (2021) These are apparent in the conditions in which people live and work every day as well as social factors, education, employment status, income level and wealth, gender and ethnicity which all have an influence on how healthy a person is.
Social Determinants of Health
Income and Income Distribution
Education
Unemployment and Job Security
Employment and Working Conditions
Early Childhood Development
Food Insecurity
Housing
Social Exclusion
Social Safety Network
Health Services
Aboriginal Status
Gender
Race
Disability
We also need to consider those groups such as LGBTQ, Black and Indigenous Peoples experiences of discrimination, related to their sexuality, race and poverty. These too are all social determinants of health.
Health inequities
WHO states that “health inequities are systematic differences in the health status of different population groups. These inequities have significant social and economic costs both to individuals and societies. “(World Health Organization [WHO], 2018)
There is abundant evidence that these factors influence how healthy a person is. In all countries there are wide-ranging disparities in the health status of different social groups. The lower an individual’s socioeconomic position, the higher their risk of poor health. Mikkonen & Raphael refer to this variation in income of different groups of people as the "social gradient." The social gradient demonstrates simply that the more money you make the better your health is, where the less you make the poorer your health is. Even when we look at our own country Canada, although we are considered one of the most affluent in the world, but we still have a social gradient. As we have high levels of overall population health status the effects of income on health but also the importance of income as a means of gaining access to other social determinants of health such as education, food, housing, recreational activities, and other societal resources.
When we think of health inequities, we have a tendency to think of this as a problem that is predominantly of the poor, but in reality, it is a problem that affects all of society This problem belongs to all of us and it is our commitment to a fair health care system that requires equitable public policies and political choices.
As a Canadian I have always been proud of our healthcare system even though aware that it was not perfect. Governmental responsibility in setting public policies in relation to SDH and choosing to overlook the impact on SDH is not a prescription for a healthy Canada. The SDH are complex and intertwined, good public policy created by informed governments can strengthen these social determinants and provide means of both promoting health in general and reducing health inequalities to a minimum.
The World Health Organization sees health damaging experiences as resulting from “a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics”. (World Health Organization [WHO], 2018)
In the document Social Determinants of Health: The Canadian Facts the authors argue that as “one of the world’s biggest spenders in health care, we have one of the worst records in providing an effective social safety net. What good does it do to treat people’s illnesses, to then send them back to the conditions that made them sick?” (Mikkonen, n.d.)
There is a great need to change negative social determinants and to reduce health disparities. Pasket et al argued that “most disparities interventions focus on the individual, often ignoring the person’s social and physical environments.” (2016)
As Canadians we rate amongst some of the healthiest people in the world. However, the report Key health inequalities in Canada “shows, the benefits of good health are not equally enjoyed by all Canadians. Some of these observed inequalities are consistent with what is known from other research on the social determinants of health and health equity, while others remain to be more fully explored. Regardless, the persistence, breadth, and depth of health inequalities in Canada constitute a call to action across all levels and sectors of society.” (2018) This report also lays out action principles and practices that can be adapted to advance health equity within the Canadian context.
1. Adopt a human rights approach to action on the social determinants of health and health equity. A human rights approach recognizes that equitable access to opportunities for health, well-being, and their determinants is an issue of fairness and justice. The right to health in particular is recognized in a number of United Nations covenants and conventions to which Canada is a party, including the International Covenant on Economic, Social and Cultural Rights. Implementation of a human rights approach to health can be supported by evidence-based, participatory, and coherent action across governments and sectors, including working with communities most affected by health inequalities to design interventions that are both relevant and effective.
2. Intervene across the life course with evidence-informed policies and culturally safe health and social services. Advantages and disadvantages in health and the distribution of its social determinants accumulate over an individual's life course and over generations. Interventions at different life stages, particularly during critical or sensitive periods (e.g. early years) can substantially affect health outcomes and health equity.
3. Intervene on both proximal (downstream) and distal (upstream) determinants of health and health equity. Public health actions that focus on individual-level behavioural determinants may inadvertently increase health inequalities in the absence of accompanying efforts that target "upstream" socioeconomic, political, cultural, and environmental factors.
4. Deploy a combination of targeted interventions and universal policies/interventions. Policy and program interventions may be specifically targeted towards those with the poorest health outcomes and greatest social disadvantage, or they may be designed for universal delivery across the whole population but implemented at different levels of intensities depending on the varying needs of specific sub-groups ("proportionate universalism"). Pairing targeted and universal interventions helps ensure that the targeted intervention effects are not "washed out" by broader conditions that may sustain social inequalities.
5. Address both material contexts (living, working, and environmental conditions) and sociocultural processes of power, privilege, and exclusion (how social inequalities are maintained across the life course and across generations). Both material deprivation and sociocultural processes that maintain privilege and disadvantage and inclusion and exclusion play important roles in generating and reinforcing social and health inequities. In addition to addressing material conditions, effective action on health equity must also include efforts to empower disadvantaged communities and tackle the harmful processes of marginalization and exclusion (e.g. systemic discrimination and stigmatization) embedded in hierarchies of power and privilege.
6. Implement a "Health in All Policies" approach. Recognizing that many of the policy levers that influence the social determinants of health lie outside of the health sector and, as such, can only be addressed through collaborative engagement with others, the World Health Organization has developed a "Health in All Policies" framework to support government sectors in systematically taking into account the health implications of their policy decisions in order to better avoid harmful health impacts and improve population health and health equity.
7. Carry out ongoing monitoring and evaluation. Improving population health and health equity requires current, systematic, and robust evidence to inform policy actors, practitioners, community organizations, and citizens about how health and its determinants are distributed across subpopulations, and how policies and interventions affect health and health equity. Ongoing monitoring and reporting on the magnitude and trends of health inequalities and their determinants supports public actors in evaluating their progress.
What Can We Do?
The reduction of health disparities and inequities leads to improved health outcomes not just of an individual but also the community in which they live. Evidence has shown that the overall health of the community can be improved by reducing disparities.
Reducing the health care needs of those low socioeconomic populations and other disadvantaged groups can decrease cost and lead to a positive outcome by reducing demands on the delivery of health services.
As a Country we need to challenge health inequities which requires effort, innovation and creativity. As Canadians in collaboration with local and federal governments, community partners and the acknowledgement that we have a shared responsibility to address inequities we will be able to reduce these gaps in our society which will lead to a better life for all.
Canadian Institute for Health Information. (n.d.). Health inequalities | cihi.
Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security. (2005). Reducing health disparities - roles of the health sector : Discussion paper [PDF]. https://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf
Government of Canada. (2018, May 28). Key health inequalities in Canada: A national portrait – executive summary - Canada.ca. https://www.canada.ca/en/public-health/services/publications/science-research-data/key-health-inequalities-canada-national-portrait-executive-summary.html
Paskett, E., Thompson, B., Ammerman, A. S., Ortega, A. N., Marsteller, J., & Richardson, D. (2016). Multilevel interventions to address health disparities show promise in improving population health. Health Affairs, 35(8), 1429–1434. https://doi.org/10.1377/hlthaff.2015.1360
World Health Organization. (1948). https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1
World Health Organization. (2018, February 22). Detail. https://www.who.int/news-room/facts-in-pictures/detail/health-inequities-and-their-causes
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