Dennis Raphael

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines—epidemiology, sociology, political economy, and the human rights perspective—to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.

Barriers to addressing the social determinants of health: Insights from the Canadian experience

Despite Canadas reputation as a leader in health promotion and population health, implementation of public policies in support of the social determinants of health has been woefully inadequate. The continuing presence of income, housing, and food insecurity has led to Canada being the subject of a series of rebukes from the United Nations for failing to address child and family poverty, discrimination against women and Aboriginal groups, and most recently the crisis of homelessness and housing insecurity. In this article we consider some of the reasons why this might be the case. These include the epistemological dominance of positivist approaches to the health sciences, the ideology of individualism prevalent in North America, and the increasing influence on public policy of the marketplace. Various models of public policy provide pathways by which these barriers can be surmounted. Considering that the International Commission on the Social Determinants of Health will soon be releasing its findings and recommendations, such an analysis seems especially timely for understanding both the Canadian scene and developments in other nations.

“Who Do They Think We Are, Anyway?”: Perceptions of and Responses to Poverty Stigma

In this article, we report on qualitative findings pertaining to low-income peoples perceptions of and responses to “poverty stigma,” a key component of social exclusion with important implications for health and well-being. Our findings are drawn from a multimethod study designed to investigate experiences of social exclusion and social isolation among people living on low incomes. We conducted semistructured individual interviews (n = 59) and group interviews (total n = 34) with low-income residents of two large Canadian cities. Data were analyzed using thematic content analysis techniques. Participants overwhelmingly thought that other members of society tend to view them as a burden to society—as lazy, disregarding of opportunities, irresponsible, and opting for an easy life. Low-income people responded to perceived stigma with a variety of cognitive and behavioral strategies that reflected their efforts to reconcile their perceived “social” and “personal” identities. These strategies included confronting discrimination directly, disregarding responses from others, helping other low-income people, withdrawing and isolating themselves from others, engaging in processes of cognitive distancing, and concealing their financial situation.

Diabetes prevalence and income: Results of the Canadian Community Health Survey

UNLABELLED This paper contributes to a growing body of literature indicating the importance of income as a key socioeconomic status marker in accounting for the increased prevalence of type 2 diabetes (T2DM). METHODS We analyzed data from the Canadian Community Health Survey cycle 3.1 conducted by Statistics Canada. Descriptive statistics on the prevalence of self-reported diabetes were computed. Multiple logistic regression was used to examine the association between income and prevalence of T2DM. RESULTS In 2005 an estimated 1.3 million Canadians (4.9%) reported having diabetes. The prevalence of T2DM in the lowest income group is 4.14 times higher than in the highest income group. Prevalence of diabetes decreases steadily as income goes up. The likelihood of diabetes was significantly higher for low-income groups even after adjusting for socio-demographic status, housing, BMI and physical activity. There is a graded association between income and diabetes with odds ratios almost double for men (OR 1.94, 95% CI 1.57-2.39) and almost triple for women (OR 2.75 95% CI 2.24-3.37) in the lowest income compared to those in highest income. CONCLUSION These findings suggest that strategies for diabetes prevention should combine person-centered approaches generally recommended in the diabetes literature research with public policy approaches that acknowledge the role of socioeconomic position in shaping T2DM prevalence/incidence.

Frailty: constructing a common meaning, definition, and conceptual framework.

The term frailty has been used for many years, both in everyday and academic language. It is a term that appears, on the surface, to be simple enough in its meaning, yet it has been used in a variety of ways to describe both people and a condition that applies to people. Moreover, little conceptual thought has gone into the nature of frailty and the factors that might affect it. This paper presents a definition of frailty: frailty occurs when there is diminished ability to carry out the important practical and social activities of daily living. It also presents a conceptualization of frailty that specifies its basic components, the categories of factors that contribute to it, and its relationship to closely related concepts.

Canada: a land of missed opportunity for addressing the social determinants of health.

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organizations Commission on Social Determinants of Health. In this regard, Canadas recent performance suggests a bleak prognosis. Canadas track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canadas capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.

Quality of life indicators and health : Current status and emerging conceptions

Quality of life is an increasingly common theme in the health status and health promotion literatures. Six approaches that consider quality of life and health are reviewed. These are (a) health-related quality of life; (b) quality of life as social diagnosis in health promotion; (c) quality of life among persons with developmental disabilities; (d) quality of life as social indicators; (e) the Centre for Health Promotion (University of Toronto) model, and (f) Lindstroms quality of life model. Each approach is considered as to its emphasis on objective or subjective indicators, individual or system-level measurement, value-laden or value-neutral assumptions, and potential relationship to social policy and social change goals. The links among the social indicators, quality of life, and health promotions areas are examined.

Making the links between community structure and individual well-being: community quality of life in Riverdale, Toronto, Canada.

An inquiry into community quality of life was carried out within a framework that recognizes the complex relationship between community structures and individual well-being. Through use of focus groups and key informant interviews, community members, service providers, and elected representatives in a Toronto community considered aspects of their community that affected quality of life. Community members identified strengths of access to amenities, caring and concerned people, community agencies, low-cost housing, and public transportation. Service providers and elected representatives recognized diversity, community agencies and resources, and presence of culturally relevant food stores and services as strengths. At one level, findings were consistent with emerging concepts of social capital. At another level, threats to the community were considered in relation to the hypothesized role neo-liberalism plays in weakening the welfare state.

The social determinants of the incidence and management of type 2 diabetes mellitus: are we prepared to rethink our questions and redirect our research activities?

This paper discusses the role played by social determinants of health in the incidence and management of type 2 diabetes mellitus (diabetes) among vulnerable populations. This issue is especially important in light of recent data from Statistics Canada indicating that mortality rates from diabetes have been increasing among Canadians since the mid‐1980s, with increases being especially great among those living in low‐income communities. Diabetes therefore appears – like cardiovascular disease – to be an affliction more common among the poor and excluded. It also appears to be especially likely to afflict poor women. Yet we know little about how these social determinants of health influence diabetes incidence and management. What evidence is available is provided and the case is made that the crisis in diabetes requires new ways of thinking about this disease, its causes, and its management.

Health inequalities in Canada: Current discourses and implications for public health action

Data concerning increasing economic inequality and its effects are increasingly becoming available in Canada. Warnings concerning the consequences of increasing economic inequality are primarily being raised within the social development sectors. The primary message is that economic inequality is creating poverty, a situation that should, on principle, be unacceptable to Canadians. The health effects of economic inequality and poverty are known to many public health professionals, but with few exceptions, public health responses are usually limited to the delivery of ameliorative programmes to those living in poverty. While federal, some provincial, and public health association documents include economic inequality as a determinant of health, discussions of the role that economic inequality plays in creating poverty, its impact upon community structures that support health, and the causes of increasing inequality are for the most part, isolated from public health discourse. Evidence of, and reasons for, resistance to such analyses and potential courses of action for addressing economic inequality and its health effects are presented.