Having control over your health outcomes is a privilege

Most Canadians believe their health is primarily influenced by their choices, such as smoking, exercising, and diet (Canadian Council on Social Determinants of Health, 2015). In reality, the primary factors that shape the health of Canadians are the living conditions they experience, known as the social determinants of health (SDOH) (Mikkonen & Raphael, 2010). The following video is a great introduction to the SDOH (Limelight Creative Media, 2018).

The Public Health Agency of Canada (2020) lists 12 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 behaviours, access to health services, biology and genetic endowment, gender, culture, and race/racism. The Office of Disease Prevention and Health Promotion (2020) organizes the SDOH around five domains: economic stability, education, health and health care, neighbourhood and built environment, and social community context, as shown in Figure 1. In this post I will explore the five domains of the SDOH, discuss their importance, relatedness to health status, and identify ways to improve. I will also discuss how social determinants of health are related to health inequities.

Figure 1. Five domains of the social determinants of health (Office of Disease Prevention and Health Promotion, 2020).

Economic Stability

Economic stability encompasses poverty, employment and working conditions, food insecurity and housing instability (Office of Disease Prevention and Health Promotion, 2020). Income may be the most important determinant of health as if effects almost all other determinants either directly or indirectly. Lynch et al. (1998) studied the associations between income inequality and mortality in 282 metropolitan areas in the United States. They found that areas with high income inequality and low average income had excess mortality of nearly 140 deaths per 100,000 compared to areas with low inequality and high income (Lynch et al., 1998). Economic stability can be improved through increased access to job opportunities, and increased availability of resources such as safe and affordable food and housing (Office of Disease Prevention and Health Promotion, 2020). While income and employment are crucial factors, stressful or unsafe work is associated with poorer health (Amit, n.d.). Therefore, focus should also be put on the type of work available (Amit, n.d.).

Education

Education includes early childhood education and development, high school graduation, enrollment in higher education, language, and literacy (Office of Disease Prevention and Health Promotion, 2020). Education is associated with both social position as well as job opportunities, income security, and job satisfaction (Amit, n.d.). Education can be improved through access to educational opportunities and facilities, improving the quality of education, and providing economic and social support for people of low-income to achieve higher education (Office of Disease Prevention and Health Promotion, 2020).

Health and health care

Health and health care incorporates access to health care, access to primary care, and health literacy (Office of Disease Prevention and Health Promotion, 2020). Primary care physicians play an important role in preventative care, therefore, areas with insufficient availability of, and access to, family doctors will have poorer health. Health literacy is defined as, “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Amit, n.d.). Health and health care can be improved by improving access to health services and health literacy. One approach to this would be incentivising primary care physicians to practice in lower-income and rural areas.

Neighbourhood and built environment

The neighbourhood and built environment includes access to foods that support healthy eating, rates of crime and violence, environmental conditions, and quality of housing (Office of Disease Prevention and Health Promotion, 2020). Quality of housing includes the physical environment such as air and water quality, as well as the social environment such as neighbourhood safety (Amit, n.d.). The neighbourhood and built environment can be improved through improving public safety measures, access to safe and reliable transportation, increased green spaces, and limiting (or eliminating) exposure to toxic substances (Office of Disease Prevention and Health Promotion, 2020).

Social and community context

Social and community context encompasses civic participation, discrimination, incarceration, and social cohesion (Office of Disease Prevention and Health Promotion, 2020). The availability of community-based resources that support community living and recreational activities contributes to health (Office of Disease Prevention and Health Promotion, 2020). Exposure to racial discrimination is associated with poorer health outcomes, reduced access to health care and poorer patient experiences (Stanley et al., 2019). Teaching compassion and educating yourself and others about racial discrimination and unfounded beliefs is an individual-level approach to combating racism.

Social determinants and health inequities

Social determinants of health are interrelated and often compounding. Income has a direct effect on health outcomes and access to health services. Individuals with low-income may be faced with challenges such as transportation to appointments, inability to pay for prescription or over-the-counter medication, inability to miss work for appointments, and inability to afford healthy foods (Center for Health Progress, 2013). Income also has indirect effects on health outcomes, such as ability to earn a higher education, inadequate housing, and adverse working conditions (Center for Health Progress, 2013; Mikkonen & Raphael, 2010).

While it may seem as though an individual can overcome these factors through personal choices and decision making, this is rarely true. A systematic and all-encompassing approach is needed to address key issues such as access to employment, education and health services (especially in rural areas), social support and community belonging initiatives, access to safe and affordable housing, addressing stigma and discrimination, and access to opportunities for physical activity and affordable healthy food (Public Health Agency of Canada, 2019). These issues require robust policy development and implementation on federal, provincial, and municipal levels.

Aboriginal peoples of Canada have adverse social determinants of health and adverse health outcomes (Mikkonen & Raphael, 2010). The history of colonization, disregard for land claims, relocation of communities, and establishment of residential schools are all linked to poorer health outcomes (Mikkonen & Raphael, 2010). The Aboriginal population has higher rates of infectious and chronic diseases and a suicide rate five to six times higher than non-Aboriginal Canadians (Mikkonen & Raphael, 2010). This is unacceptable, and as a country we need to do better.

Conclusion

While personal choices, such as abstaining from smoking, limiting alcohol consumption, exercising regularly and consuming healthy foods are all important and beneficial for your individual health, it is important to remember that at a population level, the primary determinants of health are related to the conditions in which you are born, grow and live. If you have the means to purchase healthy food (or food at all), the time and energy to exercise (maybe even have a gym membership), access to health services (no concerns with transportation, paying for medication, or out-of-pocket services such as massage, podiatry, or physiotherapy), you are privileged. If in the past you have blamed individuals for their poor health outcomes, take a step back and learn about what factors led to these outcomes. It may seem like a personal choice to smoke, and on one level it is, but in the larger picture, there are likely several environmental factors outside of ones control that led them to both start smoking and lack the support to stop smoking. Treat others with compassion and advocate for policy reform, so in the future we can have health equity in Canada.

References

Amit, S. (n.d.). What are the Determinants of Health? https://www.colleaga.org/article/what-are-determinants-health20

Canadian Council on Social Determinants of Health. (2015). A Review of Frameworks on the Determinants of Health. http://ccsdh.ca/images/uploads/Frameworks_Report_English.pdf

Center for Health Progress. (2013). ART OF HEALTH CARE: VIDEO. https://centerforhealthprogress.org/blog/publications/art-of-health-care-video/?gclid=CjwKCAjwz6_8BRBkEiwA3p02VUqXgRT6dGCvm10URRlP0GMPD7KZlUphK5R2fq1-qv-vPS77JKFbkxoCv1cQAvD_BwE

Limelight Creative Media. (2018). Social Determinants of Health Animation. https://www.youtube.com/watch?v=pbP1_qd5FHQ

Lynch, J. W., Kaplan, G. A., Pamuk, E. R., Cohen, R. D., Heck, K. E., Balfour, J. L., & Yen, I. H. (1998). Income inequality and mortality in metropolitan areas of the United States. American Journal of Public Health, 88(7), 1074–1080. https://doi.org/10.2105/ajph.88.7.1074

Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts.pdf

Office of Disease Prevention and Health Promotion. (2020). Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Public Health Agency of Canada. (2019). Understanding the report on Key Health Inequalities in Canada. https://www.canada.ca/en/public-health/services/publications/science-research-data/understanding-report-key-health-inequalities-canada.html

Public Health Agency of Canada. (2020). Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Stanley, J., Harris, R., Cormack, D., Waa, A., & Edwards, R. (2019). The impact of racism on the future health of adults: protocol for a prospective cohort study. BMC Public Health, 19(1), 346. https://doi.org/10.1186/s12889-019-6664-x