Toba Bryant

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.

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.

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.

Unmet healthcare need, gender, and health inequalities in Canada

Unmet healthcare need should be rare in nations with a universally accessible publicly funded healthcare system such as Canada. This however is not the case. This study examines the extent to which predictors of such need are consistent with various paradigmatic approaches (e.g., structural-critical, social capital, social support, and lifestyle) that consider such issues. Analyses of data from a probability sample of 2536 urban residents in British Columbia specified the relationship of unmet need with socioeconomic issues such as income, gender, and housing tenure, community issues such as social networks and social support, and traditional lifestyle or behavioural risk factors. The structural-critical model concerned with socio-demographics provided the most parsimonious explanation for having an unmet healthcare need. Consistent with a structural-critical approach, gender was found to be a reliable predictor of having an unmet health need in each of the models tested. Increasing federal transfers to healthcare and providing childcare and other community supports that are of special value for women may help to reduce unmet healthcare need.

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations – and this is especially the case in North America – recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies – the political systems that seem most amenable to securing the social determinants of health - are identified as key to promoting health. Health promoters and population health researchers need to “get political” and recognize the importance of political and social action in support of health.

The dynamics of the relationship between diabetes incidence and low income: Longitudinal results from Canada's National Population Health Survey

UNLABELLED This paper sheds light on the dynamic relationship between peoples experiences of low income and the development of type 2 diabetes (T2DM) by moving beyond the static perspective provided by cross-sectional studies to a long-term approach informed by longitudinal analyses. METHODS We analyzed data from the Canadian National Population Health Survey (NPHS) conducted by Statistics Canada from 1994 to 2007. The longitudinal sample is composed of 17,276 respondents (8046 males, 9230 females) 12 years of age or older. We further developed an algorithm to distinguish T2DM from other types of diabetes. Proportional hazard models with time-varying predictors were used to explore the dynamics of the relationship between low income and T2DM. RESULTS The results suggest that living in low income and experiencing persistent low income are significant precursors of developing T2DM. Being in low income in the previous cycle of T2DM onset was associated with 77% higher risk of T2DM (hazard ratio 1.77; 95% CI: 1.48-2.12). The association between low income and diabetes incidence remains significant after adjusting for age, sex, health behaviors, and psychological distress (hazard ratio 1.24; 95% CI: 1.02-1.52). CONCLUSION This study contributes to the under-developed research examining longitudinally the relationship between socioeconomic status and diabetes incidence. Employing this long-term approach, this study calls attention to the primary effect of socioeconomic position on diabetes incidence that cannot be explained entirely by behavioral factors. Findings draw attention to the need to address the role played in T2DM by the inequitable distribution of the social determinants of health.

A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes

Type 2 diabetes (T2DM) is a serious life-threatening chronic disease whose prevalence is especially high among Canadians living in poverty. And these Canadians with T2DM in poverty are especially likely to experience serious consequences of the disease. Of special concern is Statistics Canada reporting an explosive increase in mortality rates from diabetes (of which 90% represent T2DM) in low-income urban neighbourhoods across Canada. We place findings from interviews with 60 Canadians with T2DM who live in poverty within the context of recent shifts in public policy that have affected the distribution of the social determinants of health. Findings of material deprivation among our participants indicate that it is almost impossible for these individuals to acquire the diet necessary to prevent the adverse outcomes associated with T2DM. These findings draw attention to consideration of the important role public policy plays in affecting the situation of people living in poverty who are afflicted with T2DM and other chronic diseases.

A critical examination of the hospital restructuring process in Ontario, Canada

Little work has been done to consider the roles of different forms of knowledge and civil society actors in health policy development. Research on the role of knowledge in policy change has focussed on the contributions of social science knowledge and social scientists. This view assumes that the perspectives and knowledge of experts are the only valid input into the process and is non-critical in its analysis of health policy and health inequities. This paper challenges the reliance upon certain types of knowledge that are brought to bear on the health policy change process, and that knowledge and its creation are impartial activities. This paper presents a conceptual framework of health policy change that incorporates broad concepts of knowledge and civil society actors as contributing to health policy development. It also demonstrates the different dynamics that impinge upon knowledge and its use in health policy change. A case study on hospital restructuring in Toronto, Canada, is presented. Womens College Hospital fought recommended closure and merging of its inpatient services with Sunnybrook Health Science Centre. The case study examined the selection and use of knowledge by the Hospital in building its case against closure.

How knowledge and political ideology affects rental housing policy in Ontario, Canada: application of a knowledge paradigms framework of policy change

A case study of the Tenant Protection Act in Ontario, Canada is presented. A Conservative government elected in 1995 introduced an Act to deregulate rents and amend the Ontario Human Rights Code to allow use of income criteria to screen potential tenants. Document review and in‐depth interviews with tenant advocates were applied to understand how tenant advocates in Toronto used knowledge and other strategies to influence the legislation in the context of a new framework of policy change. The findings revealed that while different forms of knowledge, scientific, anecdotal and critical, had some influence on the process, the political ideology of the government played a significant role in determining the influence of opponents to legislation. The research concludes that while the neo‐liberal political ideology of the government did not consistently influence policy making in all areas, housing policy was particularly sensitive to political ideology. While the views of tenants did not influence the Conservative government, they did influence the policies of the Opposition parties that called for the restoration of social housing and rent control. On 2 October 2003, an Opposition party supporting these positions was elected in the Ontario general election.

Identifying and strengthening the structural roots of urban health in Canada: participatory policy research and the urban health agenda.

An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research and action agenda with four components: a) an emphasis on health promotion and the social determinants of health; b) community-based participatory research; and c) drawing on the lived experience of people to influence d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action on public policy.