Promoting Health and Reducing Social Inequalities Through Action on the Social Determinants of Health
The following highlights key points presented in Dr. Dennis Raphael’s opening keynote address at the OASW Provincial Conference on November 26, 2010. The PowerPoint slides of his presentation are posted on OASW’s website: www.oasw.org . Dr. Raphael launched the Conference, a major theme of which was the Social Determinants of Health. He has written, taught and presented extensively on this subject, and is considered Canada’s leading expert and advocate. The audience was very engaged throughout his presentation, and he was rated extremely highly in the Conference online evaluation.
Social workers, like other health professionals, have the goal of improving health and reducing social and health inequalities. It is becoming increasingly clear that in wealthy, developed nations such as Canada, the primary component of this effort involves reducing the inequalities in living conditions that exist and continue to grow within the population. While there is disagreement regarding how this may be accomplished, it is generally agreed upon that these differences in living conditions and their effects are unjust and unfair.
Establishing the Links
- Strong empirical relationship between living circumstances and a wide range of health and social problems in Canada.
- Strong empirical relationship between living circumstances and public policy approaches among jurisdictions.
- Health inequalities are a result of differing living circumstances -- social determinants of health -- that are shaped by public policy.
- Social determinants of health (SDOH) are the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.
- Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members.
SDOH can affect health in a number of ways:
- Social determinants define the prerequisites for health, such as shelter, food, warmth, and the ability to participate in society.
- Social determinants can cause stress and anxiety which can damage people’s health.
- Social determinants limit people’s choices and mitigate against desirable changes in behaviour2.
Health Inequities and Health Promotion Practice
Health inequities result from social inequalities rooted in Canadians’ living conditions. However, this is not the dominant view among health promoters. In fact, there are at least eight different ways in which “health promoters” – broadly defined – can take on the task of reducing health inequities relating to the social determinants of health (SDOH) and are as follows:
SDOH Discourse 1: Health Problems Result from Genetic Differences and Biological Dispositions
ASSUMPTION: Health can be improved by identifying the genes and processes that cause disease.
ACTION: Therefore, more and better biomedical research is carried out.
TO TAKE INTO ACCOUNT: Health problems may be medicalized and the societal status quo endorsed.
SDOH Discourse 2: Health Problems Result from Inadequate Access and Quality of Health and Social Services
ASSUMPTION: Health can be improved by strengthening health care and social services.
ACTION: More responsive hospitals, clinics, and social service agencies that take into account the SDOH are created.
TO TAKE INTO ACCOUNT: Focus may be limited to promoting the health of those already experiencing adverse SDOH, avoiding discussion of broader issues.
SDOH Discourse 3: Health Problems Result from Important Modifiable Medical, Behavioural, and Community Risk Factors
ASSUMPTION: Health inequities can be reduced by enabling people to make “healthy choices” and adopt “healthy lifestyles” that may also involve building “social capital”.
ACTION: “Healthy living” and behaviour modification programs and protocols are developed and evaluated.
TO TAKE INTO ACCOUNT: Programming may ignore material basis of health and social problems, and therefore avoiding discussion of broader issues.
SDOH Discourse 4: Health Problems Result from Adverse Material Living Conditions
ASSUMPTION: Health can be improved by improving material living conditions.
ACTION: Community development and participatory research, that enable people to gain control over their health, are carried out.
TO TAKE INTO ACCOUNT: Governmental authorities, who are receptive to and will act upon community voices and research findings, are assumed.
SDOH Discourse 5: Health Problems Result from Adverse Living Conditions that Are a Function of Group Membership
ASSUMPTION: Health can be improved by improving the living conditions of particular disadvantaged groups.
ACTION: Development and research activities among disadvantaged groups are targeted to improve material living conditions.
TO TAKE INTO ACCOUNT: Governmental authorities, who are receptive to such activities and anticipated outcomes, are assumed.
SDOH Discourse 6: Health Problems Result from Adverse Material Living Conditions Shaped by Public Policy
ASSUMPTION: Health can be improved by advocating for healthy public policy that reduces disadvantage.
ACTION: How public policy decisions impact health is analyzed.
TO TAKE INTO ACCOUNT: Governments, who will create public policy on the basis of its effects upon health, are assumed.
SDOH Discourse 7: Health Problems Result from Adverse Living Conditions that Are Shaped by Economic and Political Structures and Their Justifying Ideologies
ASSUMPTION: Health inequities can be reduced by influencing the societal structures that create and justify health inequities.
ACTION: How the political economy of a nation creates adverse conditions and identifies avenues for social and political action is analyzed.
TO TAKE INTO ACCOUNT: Social workers, who engage in the building of social and political movements that will improve adverse living conditions, are required.
SDOH Discourse 8: Health Problems Result from the Power and Influence of Those Who Create and Benefit from Adverse Living Conditions
ASSUMPTION: Health can be improved by increasing the power and influence of those who experience these inequities.
ACTION: Empowering the disadvantaged to gain understanding, and means of increasing, their influence and power is critically analyzed.
TO TAKE INTO ACCOUNT: Social workers, who engage in the building of social and political movements that increase the power of the disadvantaged, are required.
How Individuals and Institutions Can Influence Public Policy in Canada
- Educate the public
- Mobilize the public
- Enlist partners
- Get political.
Health promotion approaches that acknowledge the importance of public policy activity to address the social determinants of health and reduce health inequities may be the best means of accomplishing this goal. Significant barriers exist in Canada to such action. It may be necessary to elect specific political parties and modify economic and political structures to effect the reduction of health inequities. Such transformations will result in more equitable distribution of income and wealth that will reduce the profound social inequalities that spawn health inequities. Strong programs that support children, families, and women, and economies that support full employment, are required.
Dennis Raphael, PhD, is a Professor at the School of Health Policy and Management at York University. His most recent publications have focused on the health effects of income inequality and poverty, the quality of life of communities and individuals, and government decisions and policy. He is Editor of “Social Determinants of Health”, co-editor of “Staying Alive” and author of “Poverty and Policy in Canada” and “About Canada: Health and Illness”. He served as an advisor to the California Newsreel series “Unnatural Causes: Is Inequality Making Us Sick?” and the Deveaux Babin Productions Canadian documentary “Poor No More”.
Editor’s Note: The recent publication “Social Determinants of Health: The Canadian Facts” was produced as a public primer on these issues and is available at: http://thecanadianfacts.org
Key documents/links are:
About Canada: Health and Illness: http://www.fernwoodpublishing.ca/About-Canada-Health-and-Illness-Dennis-Raphael/
Social Determinants of Health: Canadian Perspectives: http://tinyurl.com/5l6yh9
Poverty and Policy in Canada: Implications for Health and Quality of Life by Dennis Raphael, Foreword by Jack Layton: http://www.cspi.org/books/poverty_and_policy_canada
1Source: Mikkonen, J. and Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. On-line at http://thecanadianfacts.org
2Source: Adapted from Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.
ANNOUNCEMENT: An article based on Dr. Cindy Blackstock’s plenary presentation entitled “When Everything Matters: The Breath of Life Theory” at the OASW Provincial Conference on November 26, 2010, will be published in a future issue of the OASW Newsmagazine. Currently, the PowerPoint slides of her presentation are posted on OASW’s website: www.oasw.org.
Cindy Blackstock is the Executive Director of the First Nations Child and Family Caring Society of Canada (FNCFCS). She has been a strong, passionate leader and advocate for First Nations children through the creation of Jordan’s Principle and the “I Am a Witness” campaign. This campaign grew out of the Canadian Human Rights complaint brought against the Government of Canada in 2007 by FNCFCS and the Assembly of First Nations, in regard to the long-standing pattern of under-funding of child welfare services and inequitable treatment of vulnerable First Nations children on reserves.