At the beginning of this unit, we were all to look at the WHO definition of health from 1948. My end thoughts and suggestions on redefining the WHO definition of health were to replace the notion of perfection with progress, focusing on adapting, maintaining, and improving overall health and wellbeing. Doing so would be more attainable and realistically open the definition to include the many dimensions of health relevant to different populations across their lifespan as aging occurs.
It's been a while since I have sat, read and took the opportunity to look at different public health websites to learn how they are educating about the social determinants of Health (SDH). These are the social and economic factors that influence people's health every day positively or negatively. These are the conditions in which people are born, grow, work, live, and age (World Health Organization, n.d.) and are not medical treatments or lifestyle choices (Raphael et al., 2020).
The Government of Canada (2020) indicates 12 social determinants of health, which include:
Income and social status
Employment and working conditions
Education and literacy
Childhood experiences
Physical environments
Social supports and coping skills
Healthy behaviors
Access to health services
Biology and genetic endowment
Gender
Culture
Race / Racism
Different models exist with differences in the number of social determinants of health. One at a York University Conference held in Toronto in 2002 expanded with 17 social determinants of health, which captures the above. However, it expands upon the importance of established safety nets and food security and the impact of globalization. It also includes additional barriers that one might experience if they live with a disability, immigrated to Canada or identify as indigenous (Raphael et al., 2020). This model's expansion is useful in explaining why some Canadians are healthier than others.
Video 1
Determinants of health - A practical approach!
(Appuhamy, 2020)
As a Public Health Nurse and as an advocate, I often talk about health as "upstream or downstream." Public Health's "Upstream" approach is to identify the root cause of the problem and solve it. Implementation of prevention and health promotion strategies are essential once an identifiable root cause is determined. If it is too late, then support is provided to modify behavior. Dr. Thea James similarly explains this approach to address social determinants of health to disrupt these structural barriers and transform a person's quality of life and health outcomes. Examples include income, financial stability, education, food access, and housing stability (Boston Medical Center, 2020, What is upstream health care?). As a health care professional, I must have a comprehensive understanding of the social determinants of health and relation to health outcomes to provide care, advocate for my clients, and collaborate with other community organizations to address my client's needs. We need to pay closer attention, support closing gaps, and decrease the barriers affected by health determinants to support better health status and equities for all.
In many of my readings, the social determinants of health, income, wealth and education stood out the most important regarding positive or negative health impacts. I cannot help but think how much of an effect addressing these three socioeconomic factors would have on the other determinates that influence health. Income, wealth and education are determinants that I would identify as upstream problems (or solutions) that require Government policy change (local, national, or globally) to improve the others. It is safe to explore that good health often comes with increased income and education and vice versa. Braveman & Gottlieb (2014) reinforces "the case that is needing to address upstream socioeconomic factors is strong, and enough is known to inform interventions, must be rigorously evaluated" (2014, p. 27).
1. Income & Wealth
Raphael et al., (2020) report that income shapes the overall conditions that affect physiological and psychological functioning and the uptake of health-related behaviors. It also determines the quality of the other social determinants of health. Canadian Public Health Association (n.d) explains that extreme differences in income amongst the population can negatively affect poverty. The consequences are magnified when all people are living in impoverished regions. "Social gradient" is the term used to define the income variation amongst individuals and groups. Even in Canada, being an affluent County, although the social gradient exists, it is often hidden by the high overall population health status (Mikkonen & Raphael, 2010, as cited in CPHA, n.d). The WHO states that in all countries, no matter the income, health and illness follow the social gradient "the lower the socioeconomic position, the worse the health" (n.d).
Often income is only discussed from an individual's perspective and how this can negatively or positively affect their health. Braveman & Gottlieb (2014) explains that children who grow up in a socioeconomically disadvantaged neighborhood face more significant challenges to health and health-promoting behaviors. "They also often experience emotional and physiological stressors, such as family conflict and instability arising from chronically inadequate resources" (Braveman & Gottlieb, 2014, p. 23). However, adjusting for depression, anxiety, and other negative emotional states has not entirely explained the effects of social factors on health (Braveman & Gottlieb, 2014). Raphael et al., (2020) describe the relationship between income and health and how there are two levels.
Relation to health and how it is related to the actual income that an individual or family receives
How overall population health relates to income equality and distribution across the population
Observation of both could prove the reason for "more equal income distribution has proven to be one of the best predictors of better overall health of a society" (Raphael et al., 2020, p. 17). Some recommendations that Raphael et al., (2020) argues that income inequality is a crucial health policy issue that needs to be addressed by Governments and policymakers. By increasing the minimum wage and providing extra financial assistance to those unable to work, reducing inequalities in income and wealth through progressive taxation to utilize revenues for universal programs and services, and more unionized workplaces (Raphael et al., 2020). Furthermore, some taxations could go towards a social safety net of programs and services that can offer protection for those enduring difficult life circumstances that can negatively affect their health and wellbeing. Gore & Kothari (2012) provides similar recommendations to help balance the distribution of wealth in Canada with a more progressive taxation structure along with an increase in the minimum wage.
2. Education
Education is an essential social determinant of health and has a close connection with income (on an individual basis and income equality). Raphael et al., (2020) explains that there are many pathways by which education leads to better health. Education achievement proves greater access to employment with job security, retirement plans, and better health insurance plans and coverage (CPHA., n.d.). One explanation for which people with a higher level of education tend to be healthier than those with less is that they often have a better understanding of the world and can recognize and influence the factors that shape their health and adopt beneficial behaviors (Raphael et al., 2020). Further education is also associated with improved health literacy. For some people, this may mean being able to follow the directions for taking prescribed medication, knowing where to go when they have questions about their health, or explaining to a healthcare provider.
By understanding health information, Individuals can take better control and manage their health. Inadequate care can often result from a person not having health literacy as they are dependent on others for knowing and providing what they need for their health (CPHA., n.d.). Another example of a policy change that would benefit young families regarding income and education could be providing affordable, high-quality childcare. I believe that this would allow more people into the workforce. It would also free up finances that expand options for further job training and educational opportunities and support healthy learning foundations for any children involved.
Raphael et al., (2020) recommendations to address some of these challenges include high-quality childcare and committed elected representatives to provide Canada's education system adequate funding for a well-developed curriculum. Another recommendation is better-managed tuition feed for post-secondary education and training, so children of lower-income families are not excluded (Raphael et al., 2020).
Infographic 1
Ontario's population: Determinants of health
(Public Health Ontario, 2015)
Thoughts Moving Forward …
In my review of the Ontario Government's resources, it has been quite overwhelming to look at all the policy approaches. Even more overwhelming is the number of programs that have been previously implemented and cut short or cancelled (i.e. Ontario Basic Income Pilot Project). The programs and services to reduce inequities and address social determinants of health are often not in place long enough to demonstrate positive long-term outcomes, sometimes may take decades or generations.
While not minimizing the powerful impact of the other determinants of health or disregarding that some people born with genetic endowments or disabilities may have a more challenging time with their health. I believe addressing income, wealth, and education would decrease some of the barriers to the other determinants if addressed at higher levels of our Government. The social determinants of health are all so intertwined, and when you look at the large picture, it isn't easy to think about which ones to address first to achieve health equity.
Better jobs? Better income? Better health? Less income usually has negative health impacts such as inadequate housing, food scarcity, decreased access to proper healthcare, poorer academic performance, or education access. More income would lessen health inequalities (whether from individual earnings or a local or national level) and barriers so that one can potentially: live in a healthy neighborhood with less overall stress; access more nutritious food that can support learning and literacy in school; higher-quality daycare; All of which could lead to a potentially higher paying job.
Some Questions to Ponder…
Do you allocate funding to better education to increase the chance for better income and all other determinants that impact health and equality? Or do you allocate funding into better income in hopes of increasing education?
References
Appuhamy, Ranil. (2020, January 24). Determinants of health – A practical approach [Video]. Youtube. http://www.utube.com/watch?v=zSuDQRjZv0
Government of Canada. (2020). Social Determinants of Health and Health Inequalities. Retrieved Feb 10, 2021, from http://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public health Reports, 129 Suppl 2 (Suppl 2), 19–31. https://doi.org/10.1177/00333549141291S206
Boston Medical Center. (2020). What is upstream healthcare? Health City. Retrieved Feb 11, 2021, from http://www.bmc.org/healthcity/population-health/upstream-healthcare-sdoh-root-causes
Canadian Public Health Association. (n.d). What are the social determinants of health? Retrieved Feb 11, 2021, from http://www.cpha.ca/what-are--social-determinants-health
Gore, D., Kothari, A., (2012). Social determinants of health in Canada: Are healthy living initiatives there yet? A policy analysis. Int J Equity Health 11(41). Retrieved Feb 10, 2021, from https://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-11-41#citeas
Public Health Ontario. (2015). Ontario's Population: Determinants of Health [Infographic]. Retrieved Feb 13, 2021, from http://www.publichealthontario.ca/-/media/documents/O/2014/ohp-population.pdf?la=en
Raphael, D., et al., (2020). Social determinants of Health: The Canadian Facts. (2nd edition). Retrieved Feb 10, 2021, from http://www.thecanadianfacts.org/The_Canadian_Facts-2nd_edu.pdf
World Health Organization. (n.d). Social determinants of health. Retrieved Jan 11, 2021, from http://www.who.int/health-topics/social-determinants-of-health/#tab=tab_1
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