Determinants of Health and Health Equity

Last week, we explored the World Health Organization (WHO) definition of health from 1948 and the need for its update to reflect modernization of health. I thought I would start this week's activity in reviewing the determinants of health by referencing the WHO definition of the Social Determinants of Health:

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”

In Canada, the following social determinants of health that have been identified:

1. Income and income distribution

2. Education

3. Unemployment and job security

4. Employment and working conditions

5. Early childhood development

6. Food insecurity

7. Housing

8. Social exclusion

9. Social safety net

10. Health services

11. Aboriginal status

12. Gender

13. Race

14. Disability

The majority of these determinants of health expand far beyond medical care and efforts to make positive changes will require awareness and action from both within and outside of the health sector. Multiple frameworks have been developed to improve understanding of how the social determinants of health can influence and interact with each other to affect health and well-being.

Frameworks on the Determinants of Health: A Deeper Understanding

The Canadian Council on Social Determinants of Health (CCSDH) published A Review of Frameworks on the Determinants of Health. This document summarizes a multitude of existing frameworks on the determinants of health from Canada and abroad. 36 frameworks were included in the review, with a focused discussion on 7 selected ones that are relevant for the Canadian context.

The “Toward Health Equity: A Framework for Action” (Daghofer and Edwards, 2009) was developed for the Public Health Agency of Canada upon analyzing national and international reports on the determinants of health. It is an action-oriented framework with a focus on Canadian priorities. Five priorities issues are identified:

1. Income and social status

2. Housing

3. Literacy and education

4. Aboriginal peoples

5. Early child development

With a goal towards reducing inequities in health, the framework is intended to guide policy and decision makers to develop leadership. It identifies a role for community engagement in six cross-cutting strategies for action: leadership, community capacity, knowledge development and transfer, investment in social policies, building of societal support, and the fostering of intersectoral action. There is a strong emphasis on social justice and governmental accountability towards actions towards health equity.

Health Equity and Knowing the Communities We Serve

With a more developed understanding of the social determinants of health, the first step towards improving health equity is to know the communities we serve as health care professionals.

As one of Ontario’s Local Health Integration Networks (LHIN), the Toronto Central LHIN is a regional health authority with a focus on health equity to ensure that all residents have equitable, quality-driven care while maintaining a focus on a sustainable health care system. With the most diverse patient population in the province, the Measuring Health Equity in Toronto Central LHIN Project aims to collect standardized patient demographic data to help achieve health equity. The organization I work for is part of this LHIN and have been collecting data since 2013 as part of 16 hospitals participating.

This introductory video summarizes the rationale for this transformative project in an effort to achieve health equity:

“There is a difference between treating people equally, and treating people equitably.”Dr. David McKeown, Medical Officer of Health for City of Toronto.

This statement was illustrated with an example by Dr. Kwame McKenzie, Medical Director for Centre for Addiction and Mental Health (4:28 in video).

In an event attended by an equal number of men and women, with the availability of the same number of washrooms for each gender, there is a trend towards formation of longer queues to the women’s washroom. A focus on equality aims to distribute resources equally, based on numbers - e.g. same number of washrooms for men and women due to 50:50 distribution of attendeess. Equity is outcome based. If the outcome is to ensure reasonable wait times, then more women washrooms should be planned.

To illustrate how the collection and understanding of patient demographic data can lead to patient-centred care, Dr. F. Leung at the St. Michael’s Hospital shared the following clinical examples:

“A patient was diagnosed with migraines. The patient had stable employment, but was supporting more people than assumed. Therefore, the physician needed to consider cost in the choice of medication”.

“A teen patient was feeling down. This led to a diagnosis of depression. However, once the sexual orientation question was answered, the provider then considered a more intensive screening regarding substances and suicide risk”.

Summary

There is evidence that innovative initiatives have been implemented to better understand the social determinants of health and to achieve health quality locally, provincially, and nationally. As with any shift in culture, the journey to success will take time. The key to success in the involvement of multiple sectors, health care and non-health care, and to learn from model initiatives across the nation.

References

Canadian Council on Social Determinants of Health. (2015). A review of frameworks on the determinants of health. Ottawa, ON: Canadian Council on Social Determinants of Health. Retrieved from http://ccsdh.ca/images/uploads/Frameworks_Report_English.pdf

Mikkonen J., Raphael, D. (2010). Social determinants of health: the Canadian facts. Toronto: York University School of Health Policy and Management.

Toronto Central Local Health Integration Network. (2017). Measuring health equity: Demographic data collection and use in Toronto Central LHIN hospitals and community health centres. Retrieved from http://torontohealthequity.ca/wp-content/uploads/2013/02/Measuring-Health-Equity-Demographic-Data-Collection-Use-in-TC-LHIN-Hospitals-and-CHCs-2017.pdf

World Health Organization. About social determinants of health. Retrieved from World Health Organization website https://www.who.int/social_determinants/sdh_definition/en/